Shaping the future for primary care education and training project. Education and Training Needs Analysis (ETNA) for 

integrated health and social care: the development of a toolkit

Stead, V and Nettleton, R

Title Shaping the future for primary care education and training project. Education and Training Needs Analysis (ETNA) for integrated health and social care: the development of a toolkit

Authors Stead, V and Nettleton, R

Type Monograph

URL This version is available at: http://usir.salford.ac.uk/17636/

Published Date 2006

USIR is a digital collection of the research output of the University of Salford. Where copyright permits, full text material held in the repository is made freely available online and can be read, downloaded and copied for non­commercial private study or research purposes. Please check the manuscript for any further copyright restrictions.

For more information, including our policy and submission procedure, pleasecontact the Repository Team at: usir@salford.ac.uk.

www.pcet.org.uk

Shaping the Future for PrimaryCare Education & Training Project

Funded by the NorthWestDevelopment Agency

Authors: Valerie SteadLancaster University

Robert NettletonThe University of Bolton

Vol: 3

2006

Education and Training Needs Analysis (ETNA)

for Integrated Health and Social Care

The Development of a Toolkit

3

ContentsPage

Executive Summary 5The Project Context: Introduction 7

Chapter One: Background Context 8

Chapter Two: Research Methodology: A collaborative approach 92.1 Methodology and Structure of the Research 92.2 Methodological Outcomes 102.3 Methods 10

Chapter Three: Development of the Education and Training Needs Analysis Tool Prototype 12

3.1 The Systematic Review of the Literature 123.2 A Survey of PCTs 123.3 Appraisal of Resources for ETNA 123.4 The Expert Reference Group 133.5 Understanding 'needs' 143.6 ETNA Tool Prototype Design 153.7 ETNA Tool Prototype Components 163.8 Delivery of ETNA 17

Chapter Four: Testing the Education and Training Needs Analysis Tool Prototype 18

4.1 The Pilot Reference Group 184.2 Facilitators' Workshop 204.3 Pilot Workshops 214.4 Final Evaluation Workshop 22

Chapter Five: Research Findings 23

5.1 Proving – Does it work? 235.2 Improving: Refining and Amending the ETNA Tool Prototype 265.3 Learning 28

Chapter Six: The Evidence and Implications for Future Education and Training Needs Analysis 316.1 Introduction 316.2 Relationships between Policy, Practice and Evidence 316.3 Implications for Research and Education and Training Needs Analysis 326.4 Summary 336.5 Conclusion 34

4

AppendicesAppendix 1 Education and Training Needs Analysis (ETNA) for Integrated Health

and Social Care in the Context of the Shaping the Future Project 35Appendix 2 Further Resources to Support Education and Training Needs 36

References 39

List of Tables and Figures

Table 1 Criteria for the Development of the ETNA Tool 15

Table 2 ETNA Pilot Evaluation Framework 19

Table 3 Summary of Pilot Findings 23

Table 4 Recommendations for the Improvement of the Tool 26

Figure 1 Developing the ETNA Toolkit: Structure of the Research 9

Figure 2 Methodology and Method: Development of the ETNA Toolkit 10

Figure 3 Pilot Phase Evaluation Instruments 19

Figure 4 Relationships between Policy, Practice and Evidence 31

5

Executive SummaryIntroductionThis report charts the development ofan Education and Training NeedsAnalysis (ETNA) Toolkit. The Toolkitaims to enable agencies to identifythe knowledge and skills required ofparticipants to work effectively withinintegrated health and social careservices and to contribute actively toservice integration. The developmentof an ETNA Toolkit is one of a seriesof outputs from Shaping the Future inPrimary Care Education and Trainingproject (www.pcet.org.uk) which isfunded by the North WestDevelopment Agency (NWDA). It isthe result of a collaborative initiativebetween the NWDA, the North WestUniversities Association and sevenHigher Education Institutions in theNorth West of England.

MethodologyThree methodological commitmentsunderpinned the development of theETNA Toolkit:

n Collaboration: Workingcollaboratively with stakeholdersin the creation and pilot of anETNA Tool prototype and the finalproduction of the ETNA Toolkit;

n Learning: Making learning anexplicit part of the study forparticipants and researchers;

n Interaction: Including ongoinginteraction between HigherEducation and health and socialcare agencies throughout theresearch.

The Development of theETNA ToolkitThe ETNA Toolkit was developed inthree phases: The creation of aprototype Tool, testing the prototypeTool with 2 pilot sites, and finalproduction of the ETNA Toolkit.

Phase 1: The prototype Tool wasdeveloped in collaboration with an

expert reference group drawn fromPrimary Care Trust's (PCTs) and SocialService departments across the NorthWest. This research group usedliterature reviews, a survey of ETNApractice amongst PCTs in theNorthwest of England and a selectivereview of training needs analysis toolsavailable on the World Wide Web todetermine key criteria for the designof a process led prototype ETNA Tool.

These criteria are:

n Relevance of the Tool forexpressed needs of theorganisation;

n Acceptability of the Tool to a widerange of users;

n Contributes to servicedevelopment;

n Maximises involvement at allrelevant organisational levels;

n Contributes to organisationalobjectives.

The ETNA Tool prototype contained asequence of exercises within a oneday workshop format, from reviewinglevel of integration and agreeing avision of integration to identifyingknowledge and skills, role profiling,gap analysis and action planning.

Phase 2: The second phase involvedpiloting the ETNA Tool prototype withthe aim of evaluating the tool in useand refining and amending the Toolfor public use. This phase includedusing a series of workshops thatemployed a range of evaluationinstruments with practitioners andtwo pilot sites to explore:

n The extent to which the Tool metits development criteria;

n How the prototype might beimproved;

n Learning from the pilot phase.

Data from the pilot phase illustratedthat there was significant value in anETNA Tool designed specifically for

integrated services, in particular, theopportunity to share and developjoint understandings of integratedworking and development issues. Thepilot phase also raised concerns aboutthe structure and content of theprototype Tool. These included theneed to structure it as a Toolkit ratherthan a Tool to enable greaterflexibility and ease of use, and theimportance of providing detailedoutcomes and worked examples ofactivities.

Phase 3: This phase involvedproducing the final ETNA Toolkitbased on findings from the pilotphase. This concerned making aseries of major changes to structureand content, in order to offer aflexible Toolkit that included:

n A range of options for deliveryand timing;

n Activities with clear purpose andexplicit outcomes;

n Worked examples of exercises;

n Less use of external frameworks;

n Clear ideas for action planning tofit in with local organisationalprovision.

OutcomesOutcomes from this research includethe ETNA Toolkit, and learningconcerning education and trainingneeds analysis for integrated healthand social care and its development.

Outcomes: The ETNA ToolkitThe ETNA Toolkit, available in theaccompanying volume, is divided intotwo parts. Part 1 introduces theToolkit and provides the backgroundand context to its development. Part2 focuses on using the Toolkit andoffers guidance on three phases ofpreparation and planning, deliveryand follow-up. It introduces theactivities that make up the Toolkitfollowing the sequence of the overall

6

process of Education and TrainingNeeds Analysis.

The Toolkit incorporates a series ofactivities designed to enable peopleto work through education, trainingand development issues related totheir service. The activities are:

n Introduction to Education andTraining Needs Analysis, visioning;

n Identifying knowledge and skills;

n Action planning.

Each activity comprises of a range ofexercises. Although designed as asequence the Toolkit enables activitiesto be facilitated as separate events.

The Toolkit introduces each activity byexplaining its purpose, offeringexamples of how it might be used,and provides expected outcomes andpotential action planning. Activitiesare process led and this involves usinggroup and interactive exercises thatenable participants to reach self-determined outcomes. Activities areintended to be workable for a rangeof services, whether established, newor proposed. Sample exercises tocomplete the activity aredemonstrated and the Toolkitappendices provide sample outlineprogrammes, a glossary of terms,references and resources.

Outcomes: LearningThe development of the ETNA Toolkithas provided insights concerningeducation and training needs analysisfor integrated health and social careand its development including:

n Education and Training NeedsAnalysis for integrated health andsocial care is important butcompetes with other priorities. Assuch it must therefore be seen ascontributing to and part of awider strategic development. Thiscalls for education and trainingneeds analysis that has relevance

to local context and recognisesthat needs vary from service toservice and locale to locale;

n Understanding and analysingeducation and training needs forintegrated health and social care iscomplex. Education and TrainingNeeds Analysis may, therefore,support the identification ofknowledge and skills forprogressive integration beyondjoint working;

n An emergent model of educationand training needs analysis basedon process led activities promoteslocal relevance and the capacity toarticulate, achieve and sustain acontext relevant vision ofintegrated service provision.

Developing the ETNA Toolkit hashighlighted the interplay of policy,practice and evidence and thetensions and challenges inherent inworking within policy while seekingto remain practice based. Acollaborative, learning and interactiveapproach to this kind of interventionenables these tensions and challengesto be made explicit, debated andinterpreted at a local level. Thisencourages research and educationand training needs analysis that offerprocesses in which such tensions andchallenges might be mapped andunderstood, and that enablecontributions to developingknowledge, policy and practice.

AcknowledgementsThe authors wish to thank membersof the project Steering Group, theproject delivery team, the expertReference Group and Pilot Sites fortheir help and advice. In addition, ourthanks to Lidia Koloczek for herassistance during the project, and toDavid Collinson, Professor ofLeadership and Organisation in theDepartment of Management Learningand Leadership at LancasterUniversity.

7

The Project Context

IntroductionCollaboration and partnershipworking between Higher Educationand the National Health Service (NHS)is an essential requirement foreffective delivery of care (UniversitiesUK 2003). The North WestUniversities Association (NWUA) andthe North West Development Agency(NWDA) are two organisations at theforefront of creating such alliances.The research project, Shaping theFuture for Primary Care Educationand Training Project is a collaborativepartnership between both theseorganisations and seven North WestHigher Education Institutions. Inaddition, the project brings togetherfor the first time all the key partnersin the health, social care andeducation sectors who are involved insupporting the delivery of integratedhealth and social care in the NorthWest Region.

These include:

n The North West DevelopmentAgency who are funding theproject as part of their key targetareas, i.e. Health;

n The North West UniversitiesAssociation;

n Three North West Strategic HealthAuthorities;

n Primary Care Trusts;

n Social Services;

n Higher Education Institutions andFurther Education Colleges.

The project has a ProjectManagement and Development teamand a participative Steering Group,which it is anticipated will be theprecursor to a close regionalpartnership intended to create realsynergies at a regional level. For easeof implementation, the project hasbeen divided into a series of WorkPackages, based on the key

objectives, each led by one of thepartner Higher Education Institutions.

Aim and objectives The main aim of the project is toidentify the evidence base for deliveryof integrated health and social care;the skills and knowledge required todeliver this care, together with thecurrent and future education andtraining needs of the North West ofEngland Primary Care Workforce.

The key objectives of the project are:

i. To provide a comprehensivesystematic review of the evidencebase for integrated health andsocial care services within theregional, international andnational contexts;

ii. To develop a Benchmarking Toolfor achieving best practice incollaborative working and deliveryof integrated health and socialcare;

iii. To develop a course finder tooland map the HigherEducation/Further Educationprovision of education andtraining which can support thedelivery of integrated health andsocial care services;

iv. To identify visions for the future,for both the health and social careworkforce and service users, oneducation and trainingrequirements needed to deliverintegrated services;

v. To develop and pilot an Educationand Training Needs Analysis Model(ETNA) for identifying theeducation and training needs ofthe primary care workforce tomeet the NHS and social careagendas.

Conclusion Ensuring that the health and socialcare workforce is educated andtrained to meet changing communityneeds is essential for current andfuture delivery of services. This projectis an opportunity for a number of keystakeholders in health, social care andeducation to collaborate in a new andunique way to address this, bothdirectly through the project outcomesand indirectly through creatingcommunities of learning across theNorth West Region.

8

Chapter 1: Background Context

The Shaping the Future Project wasdeveloped in response to rapidorganisational change andreconfiguration of services driven bynational policies challenging allstakeholders to implement and deliverincreasingly integrated services(Howarth et al, 2004). In this contextit could not be assumed that therewas an appropriate evidence base foreducation and training needs analysisor that the evidence available wasaccessible to those engaged in theprocess. This report outlines thedevelopment, piloting and refinementof an Education and Training NeedsAnalysis (ETNA) Tool (later 'Toolkit')with the purpose of assisting agenciesin identifying the education andtraining needs of participants inintegrated service deliveryenvironments.

The evidence base for this Toolkitbuilds upon outcomes of otherresearch within the Shaping theFuture Project, including a systematicreview of the literature on integratedhealth and social care; user and carerviews of integrated health and socialcare; and a workforce views survey.The systematic review of the literature(Howarth et al, 2004) provides an indepth account of the dynamic policycontext of the Shaping the FutureProject. The relationship of thedevelopment of the Toolkit to the restof the Project is depicted in Appendix 1.

While there are many examples ofintegrated health and social care inexistence its achievement remains amajor policy objective of successivegovernments in terms of strategicgoals and operational priorities atlocal level:

"The government has made it one ofits top priorities since coming tooffice to bring down the 'Berlin Wall'that can divide health and social careand create a system of integrated

care that puts users at the centre ofservice provision." (Department ofHealth (DoH) 1998:Chapter 3).

Much research has been undertakento identify the characteristics oforganisations and partnerships thatfacilitate integration (Howarth et al,2004). The ETNA Toolkit has beendeveloped in order to identify theknowledge and skills required ofparticipants to work effectively withinintegrated services and to contributeactively to service integration.

The whole notion of integratinghealth and social care affects a varietyof groups of people. It affects theagency, workers within health andsocial care, managers and leaders atall levels and also the users of theservice who provide the raison d'etrefor services. The integration of healthand social care within thecommunities served by Primary CareTrusts (PCTs) is integral to the widergoal of aiding health and social carestaff to work together with serviceusers and carers.

For workers within health and socialcare, integration means that roles andskill sets need to be determinedwithin the context of the service as awhole and in relation to thecontribution of other workers andagencies. Thus education and trainingneeds analysis links directly to theNHS policy of Agenda for Changesupporting service development forintegrated health and social carethrough workforce development andLife Long Learning for individuals inline with their development plans.

The development of the ETNA Toolkitwas undertaken as a collaborativeprocess. This collaboration involvedindividuals within health and socialcare organisations with appropriateexpertise and responsibility foreducation and service development,and also other 'Work Packages'

within the Shaping the Future Project.Hence the following chaptersdemonstrate that the methodologicalframework and its operationalisationreflect the principles of collaboration,interaction and learning that theETNA Toolkit seeks to promote.

9

Chapter 2: Research Methodology: A CollaborativeApproachThree methodological commitmentshave underpinned the developmentof the ETNA Toolkit prototype:

n Collaboration: Workingcollaboratively with stakeholdersin the creation of a Toolprototype, the development of apilot process and the finalproduction of the ETNA Toolkit;

n Learning: Making learning anexplicit part of this research forparticipants and researchers abouteducation and training needsanalysis and integrated health andsocial care;

n Interaction: Including ongoinginteraction between HigherEducation and health and socialcare agencies throughout theresearch and in the developmentof interactive evaluationinterventions as part of the pilot.

The three commitments are based onthe recognition that integrated healthand social care in primary care isemerging in policy and practice, andis open to wide interpretation(Howarth et al, 2004). This study was,therefore, concerned to work withinthe framework of sharedunderstanding of integrated healthand social care in practice. Thecommitments are also inacknowledgement of the philosophyand aims of the Shaping the FutureProject that is concerned withcollaboration and partnership,furthering learning andunderstanding of integrated healthand social care.

The methodological commitmentsencouraged an approach thatborrowed from research models suchas collaborative inquiry (Torbert,1981), problem-based methodologiesand action research (Hart and Bond1997, Stead et al,2001). Thesemodels have a number of featuresthat were pertinent to this research

including recognising practitioners asco-researchers; a commitment totheory and practice development; thecentrality of action and change inresearch; and the validity ofknowledge embedded in localpractice. This study therefore aimedto engage practitioners andresearchers in the joint developmentof an ETNA Tool prototype groundedin shared knowledge andunderstanding of the local context.There was also concern that themethodological approach shouldremain consistent throughout thetesting of the ETNA prototype andthe evaluation of the pilots.Evaluation research and methodologyillustrate that interactive andparticipatory interventions may helpin the development of stakeholderrelationships, can help to inform andinfluence organisational leaders anddecision-makers and can contributeto meeting the needs of theevaluated and evaluators (Gregory2000, Owen and Lambert 1995,Pawson and Tilley 1997).

Furthermore, research by Preskill andTorres (1999) argues that evaluationas an integral on-going processcontributes to individual, team andorganisational learning. It wastherefore hoped that the collaborativedevelopment of a process, thatinvited interaction and participationthrough evaluation activitiesembedded within the pilot, wouldraise issues that might be takenforward locally and that would aidlearning.

2.1 Methodology and Structure of the Research

Figure 1 summarises how themethodological approach informedthe structure of this research throughcollaborative work and events, usinginteractive processes and having acentral core of meetings andworkshops to share and disseminatelearning. This in turn enabled theclarification of individual and jointroles and responsibilities amongst theco-researchers (including researchersfrom Higher Education and

Figure 1: Developing the ETNA Toolkit: Structure of the research

10

practitioners).

The researchers' roles andresponsibilities were to plan andadminister events, to collect, collateand develop ideas and data and to beresponsible for final outcomes. Thepractitioners as co-researchers hadthe responsibility of sharingknowledge about their work andpractice to inform the ETNA Toolkitdevelopment, and reading andcommenting on draft materials. Forthose practitioners who alsoparticipated in pilot sites there wereadditional roles and responsibilitieswhich involved on-site planning andETNA pilot development. Jointresponsibilities included workingtogether to develop a Tool prototypeand the pilot process, and meeting toshare feedback for refinement of theprototype.

2.2 Methodological Outcomes

Anticipated outcomes in keeping withthis broad collaborative approachincluded:

n Ownership by co-researchers ofthe ETNA Tool prototype and thefinal ETNA product andcommitment to the pilot process;

n Learning for the project regardingeducation and training needsanalysis and integrated health andsocial care to enable the furtherdevelopment and refinement ofthe ETNA prototype;

n Learning for the stakeholderrepresentatives about theory inaction concerning integratedhealth and social care;

n Change and action for pilot sitesfollowing testing and evaluationof the ETNA prototype.

2.3 Methods The adoption of a collaborative,interactive and learning approachprovided a framework for themethods employed within thisresearch. These are summarised inFigure 2.

2.3.1 Reference Groups

Taking a collaborative stance meantworking with recognised primarystakeholders in integrated health andsocial care. Within the remit of thewider Shaping the Future Project, theprimary stakeholders were identifiedas those responsible for education,training and development withinPrimary Care Trusts (PCTs), teachingPrimary Care Trusts (tPCTs), and SocialService Departments (SSDs).Reference Groups were used asworking groups to develop theprototype of the ETNA Tool, to planthe pilot process and to comment onfeedback from pilot workshops.

2.3.2 Literature Searches and Reviews

While a systematic review of literatureshowed that there are key emergentthemes considered to be essentialrequirements of effective integratedhealth and social care services(Howarth et al, 2004), there appearsto be little understanding of availableeducation and training needs analysistools. In order, therefore, to developthe Toolkit it was important to learnabout currently available educationand training needs analysis tools andtheir purpose in the field of healthand social care by undertakingliterature searches and reviews.

Figure 2: Methodology and Method: Development of the ETNA Toolkit

11

2.3.3 Workshops

Workshops were viewed by theresearchers and the reference groupsas a way of working within the broadmethodological framework of acollaborative, learning and interactiveapproach. Workshops would enablepractitioners and researchers to planthe pilot process collaboratively, totest out the ETNA Tool prototypeinteractively and to share the learningfrom evaluating the pilot. Workshopsincluded:

n A facilitators' workshop for pilotsites to plan and prepare fordelivery of the Tool prototype;

n Pilot workshops where pilot sitesdeliver the ETNA Tool prototype;

n A final workshop to feedback pilotresults and agree amendments toproduce the ETNA Toolkit.

2.3.4 Evaluation Instruments

A range of instruments weredesigned to evaluate the ETNAprototype in use based aroundaspects of proving (Does the Toolwork?), improving (How can weimprove the Tool?) and learning(What can we learn from undertakingthis pilot?), (Easterby-Smith 1994). Inkeeping with the chosenmethodological approach the designof instruments was in collaborationwith the reference group and pilotsites. Instruments included interactiveexercises integral to the pilotworkshops and learning wassummarised and disseminatedthrough an agreed feedback processincluding a final pilot workshop.

12

Chapter 3: Development of the Education and TrainingNeeds Analysis Tool PrototypeThis chapter describes how an ETNATool prototype was developed; how'needs' were conceptualised,understood and expressed within theTool; the design of the Tool and itscomponents and the proposeddelivery of education and trainingneeds analysis.

In brief, the ETNA Tool prototype wasdeveloped through:

n An extensive systematic review ofthe literature – University ofSalford (Howarth et al 2004);

n A survey of ETNA practiceamongst Primary Care Trusts(PCTs) in the North West ofEngland;

n A selective review of trainingneeds analysis tools available onthe World Wide Web;

n Feedback from an expertReference Group.

3.1 The Systematic Review of the Literature

The systematic review of the literature(Howarth et al, 2004) took place inparallel with the development of theETNA Tool prototype and providedrésumés of key themes within theliterature in relation to the policycontext of integrated health andsocial care, education, competenciesand related matters. A selectivereview was undertaken as part of theETNA Toolkit development to identifywhat was readily available in thepublic domain that may be usedwithin health and social careorganisations. This involved reviewingexamples of training needs analysistools and related literature includinggrey literature, for example, availableon the World Wide Web. Anannotated list was produced(Appendix 2), a version of which isincluded within the final Toolkit as aresource for users.

3.2 A Survey of Primary CareTrust's (PCTs)

A brief survey of PCTs in the NorthWest was undertaken during thepublic launch of the Shaping theFuture Project in March 2003. Aquestionnaire was distributed seeking:

n Information about current practicein relation to education andtraining needs analysis, and

n Recruitment of expert ReferenceGroup members.

The returned questionnaires andinformal conversations indicated acurrent lack of systematic trainingneeds analysis across PCTs and aconcern to develop user friendlymethods for training needs analysis.Responses to the questionnaireindicated that education and trainingneeds analysis was not taking placeto any significant extent within PCTs.Reference Group members suggestedthat this may be due to the followingreasons:

n Training Needs Analysis is notviewed as a sufficiently highpriority at this time owing to otherpressing issues that were moreurgent than important;

·n Training Needs Analysis tools thatwere available were not widelydisseminated nor their uptakefacilitated;

n It is difficult to link the outcomesof training needs analysis toorganisational developmentinternally and to educationalprovision secured externally.

3.3 Appraisal of Resources for Education and Training Needs Analysis

Work with the expert ReferenceGroup guided the appraisal ofresources available in the publicdomain that were considered by theresearchers. This appraisal took into

account the context of policy driversaffecting integrated health and socialcare, especially workforcedevelopment and the 'modernisation'agenda including human resourcesstrategy, pay and service redesign.The resources identified are listed inAppendix 2. Some were applicable torelatively restricted contexts althoughcould be of potential use to someusers of the Tool. For example, QUILT(Quality in Linking Together EarlyYear's Partnerships) may haveparticular appeal to early yearssettings and emerging Children'sTrusts. Others, especially fromNatPaCT, focussed on organisationalfeatures rather than knowledge andskills as such. NatPaCT Competencieswere included in the systematicliterature review (Howarth et al,2004) and indirectly informed thedevelopment of content of the ETNATool.

Resources considered of direct valuewere:

n Public Health Skills Audit Tool(Burke et al 2001);

n Sainsbury Centre (2001) Model forthe Capable Practitioner;

n Changing the Workforce Toolkitfor Local Change(http://www.modern.nhs.uk);

n NHS Knowledge and SkillsFramework and DevelopmentReview (working draft andcompleted versions, Departmentof Health, 2003 and 2004).

The Public Health Skills Audit Tool(http://www.phskills.net/) wasdeveloped though a research projectfunded by the Health DevelopmentAgency with aims, methods andcontext of relevance to application tothe ETNA Tool. The research intopublic health skills crossed agencyand professional boundaries in orderto develop a common agenda. It alsosought ways of identifying skills to

13

develop the public health workforceat a variety of levels not confined topre existing occupationalclassifications. The methods employedwere congruent with themethodological commitments ofETNA development study. Theproduction of a Facilitators' Guide insupport of participatory workshopswas tried and evaluated in similarcontexts to the ETNA developmentstudy and therefore had appeal to theReference Group.

The Sainsbury Centre's model of theCapable Practitioner(http://www.scmh.org.uk/) was alsoresearch based and developed acrossa wide range of practitionersengaged in mental health serviceprovision, rather than being definedby organisational or professionaldesignations. In particular, somemembers of the Reference Group haddirect experience of the application ofthe model to training needs analysisin their own organisations. The partof the model of particular value inthis context was the simpledifferentiation of the 'capabilities'required of all workers – 'all musthave', or more selectively – 'somemust have'. For the purposes of theETNA Tool the Reference Groupagreed that this might be adapted toinclude a third category in the formof a question – 'Who should have?',reflecting the need to articulate andidentify specific roles in a potentiallyhighly heterogeneous group. This hadparticular salience for the ETNAdevelopment study as the scope ofwho might be involved in the deliveryof integrated health and social care iswide in respect of the knowledge andskills that they may bring and requireto deliver services.

The issue of defining 'content' of the'needs' that may be identified was amajor challenge for the ETNAdevelopment study. The Public Health

Skills Audit Tool (Burke, Meyrick andSpeller, 2001) and the SainsburyCentre model of the CapablePractitioner (http://www.scmh.org.uk/)both set out relevant content againstwhich needs analysis may beundertaken. The Public Health SkillsAudit(http://www.publichealth.nice.org.uk/)provides profiles for individuals orgroups that can be developed eitherthrough workshops or through use ofthe on-line version of the Tool. TheETNA development study wasconcerned to identify how and whencontent could be determined for theTool. At an early stage in the Shapingthe Future Project (March 2003) theDepartment of Health published itsdraft version of the Knowledge andSkills Framework (KSF) for Developmentand Review (Department of Health,2003). This was recognised as ahighly significant development likelyto impact upon the development ofan ETNA Tool. The KSF is linked to theimplementation of the comprehensivejob evaluation of every worker in thehealth service (other than doctors anddentist) known as Agenda forChange. The KSF sets out a range ofdomains and levels of knowledge andskills the possession or acquisition ofwhich is linked to pay andprogression. Its use is a requirementof all NHS organisations. In the lightof the earlier intelligence obtainedabout the priority accorded totraining needs analysis it seemedplausible to infer that the use of theKSF would become a 'must do' in theNHS and that any training needsanalysis would need to be at leastcongruent with the KSF if it were tobe used. The linkage of the KSF tothe ETNA Tool seemed to offer theprospect of a higher level oforganisational commitment than hadbeen manifest hitherto.

The profiles of competencies outlinedin the draft KSF were similar in designto those in the Public Health AuditTool. Also the workshop resourcesprovided in the ModernisationAgency's Changing the WorkforceToolkit for Local Change(http://www.modern.nhs.uk/home/default.asp?site_id=58) provided similarformats with which Reference Groupmembers had some familiarity in thecontext of service redesign,sometimes in the context of serviceintegration. A review of KSF domainsby the Reference Group resulted inthe selection of those domains thatwere applicable to all workers inintegrated services and those inparticular of relevance to serviceintegration, notably partnership andcommunication.

3.4 The Expert Reference Group

The expert Reference Group thatworked with the researcherscomprised thirteen volunteersrecruited from the Project Launchquestionnaire. This Reference Groupwas selected using purposivesampling to provide expertiserepresenting a range of servicesettings and organisations throughoutthe northwest. In particular the groupincluded:

n Representation from all threeTeaching Primary Care Trusts inthe North West;

n Representation from two socialservices departments and an acuteNHS hospital trust; and

n A lecturer involved in the deliveryof work based learningprogrammes linked to thedevelopment of integrated careacross organisational boundaries.

Reference Group members hadexperience of working with staff atdifferent organisational levels andwith several occupational groups

14

including social workers, generalpractitioners, nurses and allied healthprofessions.

There was no direct service userrepresentation, however, the researchteam had direct links with a study ofservice user involvement in healthcareeducation. In addition, several of theReference Group members wereworking directly with service users inservice development.

The Reference Group met three timesduring the development of the Tool.On each occasion progress with thedevelopment of the Tool was sharedwith the group. Their feedback,structured by the literature, tools andpractice reviews guided the next stepin its development.

Work with the Reference Groupindicated that education and trainingneeds analysis was important to PCTsbut not an urgent priority. At theoutset of the Project many PCTs werevery new organisations, havingrecently been formed from PrimaryCare Groups and either CommunityNHS Trusts or combined Acute andCommunity NHS Trusts. Majororganisational restructuring and thetransfer of Health Authoritycommissioning functions to PCTswere among a range of majorchallenges to which education andtraining could readily be viewed as oflesser urgency. Nevertheless, servicemodernisation and integration wereviewed as important. The ReferenceGroup were aware of a variety ofresources and initiatives that could beundertaken (notably working withprogrammes produced by theModernisation Agency and theNational Primary and Care TrustDevelopment Programme). However,these did not focus directly ontraining needs and in some cases theywere seen as too resource intensive tobe of practical use. Therefore, it wasconcluded that any education and

training needs analysis tool must beeasy to use and relevant for theexpressed needs of the organisation.

Service modernisation and integrationwere seen as requiring 'wholesystems working' and thereforerequired 'whole systems' engagementin training needs analysis. Theimplication of this was that the Toolmust be acceptable to a wide rangeof users and settings, that is, it mustbe generic.

A major study of training needsanalysis for health promotion inScotland (Health Education Board forScotland, 1995) and the HealthDevelopment Agency's (Burke et al,2001) Public Health Skills Audit Toolboth provided research basedaccounts of training needs analysistools in contexts of multi-professional,cross-agency working of relevance tothe development of the Tool.Important implications for theeducation and training needs analysisdevelopment study were: Educationand training needs analysis is valuedfor the process as much as, if notmore than, the outcomes; and thegreater the investment in educationand training needs analysis thegreater the value of the process toparticipants.

In light of these considerations theReference Group agreed that the Toolshould be process driven, shouldcontribute to service design anddevelopment, and should be designedto maximise involvement at allrelevant organisational levels.

3.5 Understanding 'Needs'When discussing the content of theTool the Reference Group revisitedthe concept of need as applied toeducation and training. It was evidentthat needs could not be determinedin advance of a vision of whatintegrated health and social caremight be. It was therefore accepted

that the ETNA Tool should includeactivities designed to facilitate a visionof integrated health and social care inthe local context of servicedevelopment and delivery. Needscould then be identified insubsequent activities based on thisagreed vision.

Lists of competencies of various kindssuch as those found in the KSF or inoccupational standards implynormative needs with an objective,authoritative status derived from theirsource. They also imply a need as adeficit to be made good througheducation and training. However,Reference Group members recognisedthat the language and presentation ofcompetencies may not articulate theunderstandings of all participants ineducation and training needs analysis.On the contrary, they may alienatesome participants or simplyoverwhelm by virtue of theireloquence and voluminouspresentation, as in the case of theextensive NatPaCT competencies.There was concern within theReference Group to recognise theimportance of 'felt needs' ofparticipants and to enable these to bevoiced as 'expressed needs'(Bradshaw, 1994). Understanding ofthis issue was highlighted byreflection on the Project's definitionof integrated health and social careas:

Care that is determined bypartnerships between health andsocial care agencies and users/carersfor the health and well being of the(local) community. (Emphasis added).

Several Reference Group membershad experience of working withcarers who had developed knowledgeand skills through their experience ofunpaid care work and they wantedthis to be recognised within theProject. This perspective shifted thefocus from needs conceptualised as

15

deficits to needs conceptualised asassets to be valued, nurtured andextended (for example throughformal recognition and furtherlearning). Research into health needsassessment in health visiting practicehas raised the risk of developing toolsthat are not valid owing to theireffect of imposing alienatinglanguage, conceptions of need andexperience of need assessment(Mitcheson and Cowley, 2003;Cowley and Houston, 2003):

Use of the instruments wasassociated with a failure to eitheridentify needs that were relevant tothe client or to enable clients toparticipate in the process.Furthermore, the controlling nature ofthe interactions, the number ofmissed cues and the possibility ofdistress caused by the insensitivity ofquestioning style are all potentiallyharmful side effects of usingstructured instruments to assessneeds. (Mitcheson and Cowley, 2003: 423).

This further encouraged a focus forthe ETNA Tool on needs as assetsrather than deficits and the provisionof a Tool that was inclusive in itslanguage.

3.6 ETNA Tool Prototype Design

The literature review, survey of PCT's,

appraisal of resources and work bythe Reference Group including theirdeveloped understanding of needsled to the design and delivery of theETNA Tool based upon the followingcriteria:

Within the frame of these criteria theReference Group agreed theStructure, Process and Outcome ofthe ETNA Tool as detailed below:

StructureTraining needs analysis needs to beembedded in a wider structure oforganisational preconditions if it is tobe adopted and the outcomesutilised. The required structures aredepicted in Appendix 1 mapped ontothe other work package elements ofthe Shaping the Future Project.

ProcessThe tool is best applied to a specificservice development. The Toolprovides a guide to supportfacilitators in the process of needsanalysis to be used in a group setting.

Tool Outcomes The outcomes are based upon thecontent of the Tool in terms ofskills/knowledge expressed ascompetencies with competency levels.These are derived from a selection ofrelevant domains of the Knowledgeand Skills Framework forDevelopment and Review

(Department of Health, 2004). Thisframework was adopted because it isa Department of Health requirementof all NHS organisations to use it andit is linked to pay and progression,supporting the implementation ofAgenda for Change. It also allows forthe inclusion of 'local competencies'that are specific to a particular servicedevelopment.

It was decided not to predetermineoccupational roles or role descriptionswithin the Tool (unlike the PublicHealth Skills Audit). Rather, thedefinition of roles would be anemergent outcome of needs analysis,expressed in terms of competenciesfor the role. The application of theserole definitions to individuals wouldresult in identification of needs forlearning and development to achievethe required competencies. Thedefinition of roles and competenciesas emergent outcomes allows theinclusion of users and carers who arenot part of the formal health andsocial care workforce. The adaptationof the 'field of words' technique,(Cowley and Houston, 2003) as a toolassists individuals and groups toarticulate the skills, knowledge and

General Criteria Specific Criteria

Relevance of Tool for expressed needs of the Shared understanding of the serviceorganisation

Acceptability of the Tool to a wide range of users Shared vision of the service

Contributes to service development Compiled role profiles for identified job roles in the service

Maximises involvement at all relevant Completed role specification sheetsorganisational levels

Contributes to organisational objectives Action plan

Table 1: Criteria for the development of the ETNA Tool

16

It was decided not to predetermineoccupational roles or role descriptionswithin the Tool (unlike the PublicHealth Skills Audit). Rather, thedefinition of roles would be anemergent outcome of needs analysis,expressed in terms of competenciesfor the role. The application of theserole definitions to individuals wouldresult in identification of needs forlearning and development to achievethe required competencies. Thedefinition of roles and competenciesas emergent outcomes allows theinclusion of users and carers who arenot part of the formal health andsocial care workforce. The adaptationof the 'field of words' technique,(Cowley and Houston, 2003) as a toolassists individuals and groups toarticulate the skills, knowledge andexperience that they bring to healthand social care. These could then bemapped onto more formalcompetencies to validate their co-participation in the workforce withthe potential for further support oflearning and development whether ornot this leads into employment.

It was envisaged that the fullimplementation of the ETNA Toolshould deliver a number of outcomesfor services and for individuals,including:

n Locally owned vision forintegrated health and social care;

n Knowledge and Skills for all – a'core curriculum';

n Knowledge and Skills for selectedroles;

n Key issues for service developmentand role design;

n Validation of individual knowledgeand skills;

n Individual development planning.

3.7 ETNA Tool Prototype Components

The Reference Group approved the

development of the following fivecomponents for the ETNA Tool:

1. Introduction and Icebreaker;

2. Visioning Exercise: integrated services;

3. Identifying Knowledge and Skills;

4. Role profiling and Gap Analysis;

5. Action Planning.

3.7.1 Introduction and Icebreaker

The inclusion of an introduction andice breaker was considered importantto engage participants in a workshopcharacterised by a highly participatoryapproach similar to the HealthDevelopment Agency's Public HealthAudit Tool (Burke, Meyrick andSpeller, 2001). The Tool offerssuggestions for facilitators but doesnot prescribe particular exercises sothat they are free to use their groupfacilitation skills as they findappropriate in their local setting.

3.7.2 Visioning Exercise: IntegratedServices

The inclusion of a visioning exercisebuilds upon the Public Health AuditTool and the Changing the WorkforceToolkit for Local Change (seeAppendix 2). The purpose of thevisioning exercise is to enable theparticipants:

n To review where the service is nowin terms of integration, and

n To explore where participantswould like the service to be in thefuture.

Reviewing the extent to which theservice is currently integrated wouldenable participants to describe theirown experience of working in anintegrated way. It would also providea starting point for envisaging changeand identification of knowledge andskills required for the delivery ofintegrated services.

3.7.3 Identifying Knowledge and Skills

The decision to define roles andcompetencies as emergent outcomesof process of interactive dialogueendorsed the adaptation of the 'fieldof words' technique (followingCowley and Houston, 2003). Thistechnique is intended to assistindividuals and groups to articulatethe skills, knowledge and experiencethat they bring to health and socialcare. In the Tool, the field of words ispopulated in the first instance withterms identified by workshopfacilitators as triggers to stimulategroup thinking. These terms areplaced randomly on a piece of flipchart paper. The pilot Tool utilised sixtrigger terms derived from thesystematic review of the literature(Howarth et al, 2004) as a startingpoint for the field of words needsassessment exercise.

These are:

n Communication;

n Team Working;

n Partnership;

n Personal/ProfessionalDevelopment;

n Service Development;

n Practice Development.

The interactive workshop setting isintended to enable participants toextend their thinking, for example, byexplaining or exploring knowledgeand skills with workers from otheragencies involved in the delivery ofservices. Work from the visioningexercise would provide the basis foridentifying:

n Knowledge and/or skill already inuse to deliver an integratedservice, and

n Knowledge and/or skill required todeliver an integrated service.

This would then offer lists of

17

knowledge and skills using these twoheadings, leading to a gap analysisfor the service as follows:

Knowledge and/or skill required todeliver an integrated service

MINUS

Knowledge and/or skill already inuse to deliver an integratedservice,

EQUALS

Gap analysis of knowledge/skillsfor an integrated health and socialcare service.

3.7.4 Role Profiling and Gap Analysis

The gap analysis may be furtherdifferentiated through the use of thefollowing categories, adapted fromthe Sainsbury Centre model of theCapable Practitioner(http://www.scmh.org.uk/-seeAppendix 2):

n All must have;

n Some must have;

n Who should have?

The Tool prototype provided guidancefor facilitators to further differentiateand classify knowledge and skillsaccording to specific roles defined byparticipants in relation to level withinthe organisation. For example, usingthe broad headings of strategicmanagerial, operational managerialand front line worker requirements.This would then enable furtherapplication through profiling ofspecific job roles. Job rolespecification sheets were provided forcompletion in relation to one or moreroles, based upon selected domainsof the Knowledge and SkillsFramework, and following themethods included in the Changingthe Workforce Toolkit for LocalChange and the Public Health AuditTool (see Appendix 2).

3.7.5 Action Planning

The ETNA Tool prototype providedguidance to facilitators:

n To identify key issues and toinform participants of how thesewill be taken forward for furtherconsideration/action within theorganisation;

n To provide opportunities forindividuals to review personaloutcomes and further action plansof importance for their owndevelopment;

n To set aside time following theworkshop along with servicemanagers to identify prioritiesarising from the needs analysis forknowledge and skill developmentfor the existing workforce andpossible new roles; and

n To evaluate the workshop andthank participants for theircontribution.

3.8 Delivery of Education and Training Needs Analysis

The five components of the ETNATool were proposed as the basis for aday workshop offered to pilot sitesrecruited for the programme alongwith locally based facilitatorssupported by the researchers fromHigher Education. It was envisagedthat the delivery of the workshopswould require three phases outlinedwithin the Tool:

n Preparation and Planning;

n Delivering a full day workshop;

n Follow-up phase – review, actionplanning.

Examples of these are provided inChapter 4 which describes the testingand refinement of the ETNA Toolprototype.

18

Chapter 4: Testing the ETNA Tool Prototype Piloting the ETNA Tool prototype hadtwo aims: To evaluate the tool in use,and to refine and amend the Tool forpublic use. In line with the adoptedmethodology the pilot phase of theresearch involved:

n Working with practitioners in theform of a Reference Group;

n Running a facilitators' workshop;

n Delivery of two pilot workshops;

n A final evaluation workshop.

Each of the components of the pilotphase is discussed below.

4.1 The Pilot Reference Group

Following the launch of the ETNATool prototype, existing ReferenceGroup members and other interestedPCTs and Social Service Departmentswere invited to work on the pilotphase of this study. This involvedidentifying potential pilot sites and aworking process, developing anevaluation framework and criteria,and designing evaluation tools.

4.1.1 Identification of Pilot Sites

Criteria for the selection of sites toparticipate in the pilot phase were:

n The target service must be eitheroperating or preparing to operateas an integrated health and socialcare service;

n The agencies must be able tocommit facilitators and time tothe process;

n Agencies must be willing toparticipate in preparation andfollow-up events concerning thepilot phase;

n Agencies must gain commitmentfrom the targeted services.

In addition, the researchers werekeen to pilot use of the Tool indifferent sites, in accordance with theaim to provide a generic ETNA Tool

that would work within theframework of service developmentacross PCTs in the North West. Fromthe expressions of interest shownthree pilot sites were initiallyidentified as pilot sites. Theseincluded PCT A, serving an urbanarea and part of a larger tPCT; PCT B,serving two semi rural communities;and PCT C, within an urban area.PCT C aimed to pilot use of the Tooljointly with the local Social ServicesDepartment and within a proposedChildren Disabilities Trust. However,ultimately they were unable toparticipate in the pilot within the timeframe of the pilot phase.Representatives from this sitecontinued to play a key role in theongoing pilot study. Therefore, thetwo pilot sites that met the criteriaand could work within the projecttimescales were:

1. PCT A with a Community OlderPeoples Team service;

2. PCT B in the proposeddevelopment of a one stop healthand social care shop for localresidents.

The reference group also agreed aprocess of support for the identifiedpilot sites including regular liaisonwith named individuals from the pilotsites, dissemination of any plans orrelevant documentation to all sites,and informing pilot sites of eachothers' pilot schedules. This processwas significant in that sites andresearchers had access to each otherin between meetings and workshops.

4.1.2 Evaluation Framework and Criteria

The pilot reference group was used todevelop an evaluation frameworkfocused around proving, improvingand learning (adapted from Easterby-Smith, 1994). This frameworkembraced evaluation criteria made upof the general criteria and specific

outcomes used in the development ofthe ETNA Tool prototype, as shown inTable 2 (on next page). Assessing theextent to which the Tool works andmeets the criteria by which it isdeveloped (proving) aimed tohighlight also where it was notworking and where it might beimproved. It was also hoped that thiswould offer learning about educationand training needs analysis inintegrated health and social care.

The Reference Group suggested atwo staged approach to the sixmonth pilot. Stage 1 was based onthe primary focus of the pilot andinvolved evaluation of the Tool in use.This stage included a facilitators'workshop where pilot site facilitatorscame together to familiarisethemselves with the Tool and plan itsdelivery, and pilot workshops wherethe pilot sites delivered and assessedthe Tool prototype. Stage 2concerned the evaluation of the Toolas enabler where pilot sites cametogether to reflect on their use of theTool and the extent to which itsupports the integration of healthand social care.

19

4.1.3 Use of Evaluation Instruments

The agreed framework encouraged the use of instruments to fit within the collaborative, interactive and learningmethodology. Figure 3 summarises the evaluation instruments for each phase.

Evaluating the Prototype: Purposes

Proving: To what extent does the Tool meet its development criteria?

Improving: How can we improve it to meet the criteria more effectively?

Learning: What have we learned from this pilot concerning education and training needs analysis and integrated health and social care.

Table 2: ETNA Pilot Evaluation Framework

Pilot Stages

Stage 1: Facilitator Workshop – Introduce the Tool and plan delivery.

Pilot Workshops – Deliver and evaluate the Tool in use.

Stage 2: Final Evaluation Workshop – Reflect on impact of the Tool.

General Criteria Specific Criteria

Relevance of Tool for expressed needs of the Shared understanding of the serviceorganisation

Acceptability of the Tool to a wide range of users Shared vision of the service

Contributes to service development Compiled role profiles for identified job roles in the service

Maximises involvement at all relevant Completed role specification sheetsorganisational levels

Contributes to organisational objectives Action plan

Stage 1 Tool in use Stage 2 Tool as enabler

Facilitator workshop: Facilitator feedback Pilot site assessment: Discussion

Pilot workshops: Observation Final evaluation workshop: Feedback views

Reflection Spots

Final Review

Facilitators’ Debrief

Figure 3: Pilot phase evaluation instruments

20

Stage 1The first stage involved evaluating theoverall ETNA Tool as well as itsconstituent parts during delivery.Evaluation instruments agreed uponincluded facilitator feedback,observation, reflection 'spots' and afinal review. Researchers andfacilitators aimed to use pre-setprompts or questions for each of thecomponents of evaluation thatrelated to general criteria and specificoutcomes.

Facilitator feedback: The facilitators'workshop, described in section 4.2,gave an opportunity to gain initialfeedback on the ETNA Tool prototype,through participation in exercises andplanning of delivery.

Observation: Project researchersintended to observe the Tool in useand in particular the processes andcontent with a view to improvement.This involved observing the extent towhich each of the five deliverycomponents met the identifiedgeneral criteria and helpedparticipants achieve the specificoutcomes. For example, ease of useof the visioning exercise and its valuein achieving a shared vision of theservice. Not all general criteria wouldbe observable within the workshop,for example, contribution to servicedevelopment and contribution toorganisational involvement.

Reflection Spots: Reflection 'spots'involved the facilitator asking theparticipating group to stop, reflectand review on the processes andexercises just undertaken. Reflection'spots' were at key points in thedelivery, for example, following thefield of words exercise. Reflection'spots' were short and focused on thevalue of the exercise in achieving theoutcome and how it might beimproved. For example, following thevisioning exercise the facilitator asked

the group to consider the value of theexercise in reaching a shared vision,what was useful about the exerciseand any improvements to content orprocess that could be made. Thisenabled the facilitator and researchersto get an immediate reaction and tosupplement observationalinformation.

Final Review: At the end of theworkshop a final review of 45minutes enabled participants toreview the overall process and tohighlight particular aspects of valueand for improvement. The finalreview asked participants to highlightwhat they found most useful andwhy and whether the overall Tool metthe general criteria.

Facilitators’ Debrief: After theworkshop, facilitators had anopportunity to review the progress ofthe workshop. In particular,facilitators were asked to reflect ontheir experience of delivering theETNA Tool, aspects they found ofvalue and aspects they think needimproving. Stage 2 would provide anopportunity for a more in-depthreview.

Stage 2Stage 2 focused on the Tool as anenabler to support development ofintegrated services and involvedevaluation after the pilot workshops.This stage included discussion as partof a pilot site assessment and sharingfeedback in a final evaluationworkshop.

Pilot site assessment: After the pilotworkshops facilitators were asked todiscuss the value of the Tool insupporting integrated health andsocial care.

Final Evaluation Workshop: A finalworkshop was arranged three monthsafter the last pilot workshop to sharefeedback from pilot sites with the

wider Reference Group. The timelapse aimed to give pilot sites theopportunity to reflect on the value ofthe ETNA Tool and to gatherinformation about its contribution toservice and practice development. Atthis final workshop, the researchersprovided initial feedback from thepilots and invited comment,additional feedback and discussionfrom the facilitators' and ReferenceGroup perspectives.

4.2 Facilitators' WorkshopThe facilitators' workshop was a oneday practical event aimed atfamiliarising representatives from pilotsites with the ETNA Tool prototype inorder to help them plan the pilotworkshops. The event was run by theresearchers and aimed for thefollowing outcomes:

n A good understanding of the Tooland how it might work on thepilot;

n A checklist for undertaking thepilot;

n Clarity about pilot site andresearcher roles throughout thepilot study;

n An action plan including nextsteps and timing.

A total of 12 participants attendedthe day including facilitators andrepresentatives from both pilot sites,and other interested members of theReference Group. The workshop wasstructured to enable participants toengage in as many of the ETNA Toolactivities as possible. This includedsimulation of the visioning andknowledge and skills exercises, andworking through a sample roleprofiling and gap analysis exercise.Feedback sessions followed eachactivity so that participants could raisequestions and consider how theymight implement the exercises withintheir own pilot sites. The workshop

21

finished with an action planningactivity. Pilot sites were asked toconsider what needed to be in placeto run the pilot within their site andto set dates for their workshops. Inaddition, roles and responsibilities ofthe pilot sites and the researcherswere confirmed. Support mechanismswere clarified including ongoingliaison, help with practicalarrangements, opportunity to attendeach others' pilot sites anddocumentation provision.

4.3 Pilot WorkshopsThe ETNA Tool prototype was pilotedin two different sites: PCT A:Community Older Peoples Team(COPT) service, which was anestablished service and PCT B whowere proposing a new service. Theresearchers attended both pilotworkshops to support the facilitators,to observe the pilot throughparticipation with groups in theactivities, and to carry out shortevaluation exercises with participantsafter the activities and at the end ofthe day.

4.3.1 PCT A Pilot Workshop

The PCT A COPT service wasdeveloped in 1999 to provideintegrated services for older peoplelocally as a result of national and localpractice and guidance. PCT A is nowseeking to further integrate its healthand social care services for olderpeople and is currently undergoing aconsultation process to consider:

n Further co-location of staff on aneighbourhood basis;

n The development of integratedworking arrangements includingworkforce, information aboutservices, information systems andmanagement structures;

n The development of integratedcommissioning between thePrimary Care Trust and the Social

Services Department;

n The mainstreaming of servicesfocused on the needs of olderpeople across each of PCT A's fiveStrategic Partnership themes(Economy & Employment; Housing& Environment and Crime).

The service has not been involved inany joint training activities before andwanted to use the ETNA Tool as partof the ongoing development ofintegrated provision.

Preparation for the one day workshopincluded sending out a pre-eventquestionnaire for participating teamsto encourage them to think aboutknowledge and skills developmentbeforehand. Over a series ofmeetings, a team of three facilitatorsdeveloped the agenda based on thesequence of activities within theETNA Tool. The facilitator team thendevised materials to support theactivities and to act as prompts forthe exercises. This material includedexercise information on flip chartsand small exercises to link activitiesand to relate them to COPT work.

There were 16 COPT members at theworkshop including representationfrom a range of professions includingphysiotherapy, social work, nursingand service managers. The workshopincluded a series of activities fromexploring current level of integrationof service to how it might be in thefuture, identifying the knowledge andskills a COPT practitioner requires andhas, and using existing roles to carryout a role profiling activity and gapanalysis.

4.3.2 PCT B Pilot Workshop

PCT B became a pilot site for theETNA Tool because they are planningan integrated Health ConnectionsCentre to provide access to health,social and welfare services includingservices provided by the voluntary

sector. The Centre aims to be a drop-in service that links into a range ofother amenities such as benefitsadvice, a Sure Start crèche, libraryaccess, a café and learning suite. TheCentre proposes to offer local peopleaccess to a range of health and socialcare services including Physiotherapy,Podiatry, Nutrition and dietetics,dentist and community dentalservices, mental health and learningdisabilities services, school healthpractitioners, citizens' advice andyouth services. The Centre hopes todevelop new ways of working bybuilding on current joint workingarrangements for example childdevelopment teams that includeaudiology and speech therapists,health visitors and sure start workersand learning mentors. This may meanfuture integrated provision thatincludes a range of existing and newroles working together, for example,benefits advisers, housing workers,key workers and visiting volunteersworking as an advocacy team.

PCT B wanted to use the ETNA Toolas a development starting point thatwould bring representatives from arange of agencies together to exploreinitial needs.

Preparation for the PCT B pilotworkshop included a briefing eventfor stakeholder services to introducethe ETNA Tool prototype and to helpidentify an agenda. This pilot wasdeveloped by three facilitators. Oneof the facilitators had attended thePCT A pilot and used this experienceto plan the event in PCT B. Theworkshop was attended by 16 peopleincluding social workers, districtnurses, nursery and schools officersand service managers. The agendaincluded asking participants toexplore current level of integration ofservice to how it might be in thefuture and to identify their workingdefinition for integrated health and

22

social care. The group then identifieda key 'joint' role within the proposedCentre and worked with this role toanalyse the knowledge and skillsalready available within the service forthis role and any further additionalrequirements. The participants werethen asked to develop a gap analysisand role profile for the role.

4.4 Final Evaluation Workshop

The second stage of the pilot wasconcerned with the extent to whichthe Tool supported the developmentof integrated services. It aimed to dothis by asking pilot sites to reflect onthe value of the Tool following theirpilot workshops and to share theirviews within a final evaluationworkshop. The final evaluationworkshop took the form of a half daymeeting three months after the finalpilot workshop. The time lapse aimedto give pilot sites the opportunity toreflect on the value of the ETNA Tooland to gather information about itscontribution to service and practicedevelopment. A total of 12 peopleattended including pilot siterepresentatives and Reference Groupmembers. Participants were invited toundertake a review exercise thatasked them to identify benefits fromundertaking the ETNA Tool and anyactivities or changes that haveresulted from the pilot workshopsand contributed to service or practicedevelopment.

23

Data were collected from the rangeof workshops including:

n Researchers' observation ofactivities;

n Participants' views of individualactivities;

n Participants' views of the Tooloverall;

n Facilitators' feedback and pilotdebrief;

n Pilot site discussion and feedback.

The data were mapped against thegeneral and specific ETNA Toolprototype development criteria toprovide information concerning thethree purposes that underpinned theevaluation framework:

n The extent to which the Toolworked (proving);

n How the Tool might be refinedand amended (improving), and

n Insights about training needsanalysis and integrated health andsocial care (learning).

The data are presented within each ofthese categories below.

5.1 Proving – Does it work?The data show, as illustrated in Table3, that the Tool has value across eachof the identified criteria with thepotential to be used flexibly across arange of integrated services. However,the pilot phase also raises importantconcerns with the prototype.

Chapter 5: Research Findings

Table 3: Summary of pilot findings

General Criteria

1. Ease of use

2. Relevance of Tool to organisation'sneeds

3. Acceptability of Tool to range ofusers

4. Contributes to servicedevelopment

Value

Some components easy to use, forexample visioning

Enables identification of commondevelopment issues

Acceptability of the Tool across a range of professions and roles including members of public/community

Tool provides useful integrated focuson issues

Opportunity to think throughimplications of integrated working

Visioning identified commonproblems, areas to work on, overlapsin service provision

Action planning and review activitieshave taken place following the pilots

Concerns

Complex to manage

Lack of flexibility

Dependant on facilitator skill andpreparation

Timing

Process

Clarity of purpose and outcomes

Lack of worked examples

Knowledge and skills exercise and roleprofiling need further consideration

Use of the KSF problematic and hardto relate to roles in any depth

Not an 'off the shelf' tool

Facilitators require training

Some terminology is difficult

More value as Toolkit than Tool

How will actions be implementedafter workshops?

Key purpose of Tool can be confusing

Specific Criteria

To what extent did the Tool enable:

n Shared understanding of theservice;

n Shared vision of the service;

n Identification of knowledge andskills;

n Role profiles;

n Action planning.

Shared learning about roles andservices

Shared learning about different waysof working

Promoted thinking beyond own role

Identified new ways forward andpotential new roles

One pilot site successfully identified ahybrid worker role

Not enough time to do exercisesjustice in one day workshop

Identifying knowledge and skills androle profiling proved difficult,particularly use of abstract themesand KSF framework

Difficult to use a generic tool to dealwith specific roles, particularly gradeswithin a profession

Little time for action planning

24

General Criteria

5. Maximises involvement at allorganisational levels

6. Contributes to organizationalobjectives

Value

Process led model enables'interaction, discussion andintegration with other professionalswithin this community'

'Supports our 'go integral' initiative inPCT A

'Helps see how individual role fits intoand across organisations' in PCT B

Concerns

Frameworks

Fit with other provision

Table 3: continued

5.1.1 Value of the ETNA Tool Prototype

The main value for the PCT A pilotappeared to lie in enabling a range ofmulti-disciplinary professionals towork together within a service ratherthan professional role framework,and as such supported the PCT A 'gointegral' initiative. Action planningand review activities have taken placefollowing the pilot including a greaterfocus on moving forward with theirco-location plans, further work oncommunication and co-ordination ofrecords. In addition, since the pilotPCT A has had some cross-organisational development includingintegrated sessions with health andsocial care. The COPT service is alsochallenging support services to targettraining and development delivery at

integrated needs rather thanprofessional roles. PCT A recognisethat impact for service users may takemore time to become evident andthey highlighted 'hidden benefits'where the service is aware of benefitswhich service users may notrecognise, for example, improvedcommunication.

The main value for the PCT B pilotappeared to lie in offering thisparticular group an opportunity toexplore how their particular roles andservices interact already and how theymight interact within a differentsetting. Although many of theparticipants knew each other theyhad not had opportunity before toget together and to work at a servicelevel. PCT B held a facilitators' reviewof the pilot and recognised that this

has put the process of integratedworking more firmly on the agenda,particularly as the Head of Social Carehas used the pilot as evidence topush for co-location of services.

Common values identified from useof the ETNA Tool prototype include:

n Developing joint understandingsof integrated working, of servicesand roles. For PCT A this involveda more detailed understanding ofthe breadth and depth of theservice. For PCT B this involveddeveloping a joint understandingof how individual roles operatedwithin the broader servicecontext;

25

n Sharing different ways of workingacross services. Both PCT A andPCT B pilots found that 'differentprofessional roles did thingsdifferently', for example,assessment procedures;

n Identifying overlaps in serviceprovision. The concerns of PCT Aand PCT B were similar, forexample, use of multiple recordswhere one joint record wouldsuffice;

n Identifying common developmentissues. Different ways of doingthings indicated ways forward forboth sets of participants, forexample, streamlining of ITsystems;

n Acceptability of the Tool across arange of professions and roles.The pilot sites felt that this kind oftool could be useful to a wideraudience including localcommunities, service users andcarers;

n Opportunity for service membersto meet and talk away from theoperational environment.Participants on both pilots foundthe opportunity to share andnetwork very valuable. For manyof the PCT B participants this wastheir first chance to meet eachother;

n Opportunity to think throughimplications of working in anintegrated way. The pilot sites feltthat the particular focus of thisTool on integration offered arigour that other tools would not,and therefore encouraged servicesto explore implications and actionsaround the focus of integrationand training and education needs.

5.1.2 Concerns with the ETNA Tool Prototype

While the pilot sites felt overall thatthis Tool did contribute positively to

their different objectives, there wereconcerns that the content andstructure of the Tool were complexand difficult to manage. Facilitatorsthought that as a generic tool avariety of services would use the Tooldifferently and the structure andcontent needed to reflect greaterflexibility. Although some exerciseswere more easily worked throughthan others this seemed to relyheavily on facilitator skill and theparticipants' perception of theimmediate applicability to their work.For example, the visioning exerciseworked well but the skills andknowledge identification wasproblematic as themes seemedabstract and difficult to connect tothe role and task under discussion.Both pilot sites questioned the valuethat the role profiling exercise addedto the ETNA process. PCT A felt thatthe role profiling exercise did noteasily take into account differentgrades within the same professionwho may be working at differentlevels of responsibility e.g.physiotherapists. PCT B found thatalthough they did get to the point ofidentifying a role profile of a hybridassessment worker, this was a difficultand frustrating process using the KSFframework. The observers also notedthat this particular exercise appearedto have no practical value, and that itneither offered enough depth totackle the detail of individual roles orenough breadth to make it relevantto the range of potential roles. Thepilot sites also agreed that theadditional information provided towork with alongside the knowledgeand skills and role profiling exerciseswas too detailed and too complex tobe of value, and did not easily enablelinks to practice.

Although the sites found that theTool was relevant to the needs oftheir organisation, facilitators thoughtthat it needed to offer more specific

examples of how it can be used inpractice. The pilot sites thought thatthis kind of tool was applicable to awide range of users includingmembers of the public and localcommunities. However, participants atall of the pilot events agreed thatthere was too much jargon and thatfacilitators could not use this as an'off the shelf' tool but would requiretraining. The pilot sites also foundthat the exercises took more timethan anticipated and that overalltiming and planning of use of theTool needed consideration. Inparticular, the pilot sites and theReference Group agreed that actionplanning was important and neededto have more prominence in the Toolif development was to be takenforward within the organisation. Thepilot workshops found that theexercises took more time thananticipated leaving little time todevote to action planning.

There was some debate at the finalevaluation workshop around theclarity of the primary purpose of theTool and that, in its present state, itmight be viewed more as anorganisational development toolrather than an education and trainingneeds analysis tool. It was suggestedthat this may in part be because thedetail and the focus could get lost byattempting to cover the componentswithin a full day and that thesupporting documentation of the Tooldid not offer sufficient clarity ofpurpose and outcome.

Overall both sites felt that delivery ofthe Tool required a lot of preparationand facilitation. Concerns were raisedat each of the workshops about howthe service and/or organisation woulddeal with issues and actions followinguse of the Tool, and about how theTool supported current developmentalactivities or provision.

5.2 Improving: Refining and Amending the ETNA ToolPrototype

The data from both pilot stagesprovided clear and significantrecommendations for theimprovement of the ETNA Toolprototype.

These are summarised according tostructure and content in Table 4which also illustrates the proposedimpact against initial Tooldevelopment criteria that thesechanges will have.

The refined and amended version ofthe Tool, known as the ETNA Toolkitis available in a separate volume(Nettleton and Stead, 2005).

Table 4: Recommendations for the improvement of the Tool

Structure

Content

Key Recommendations

Toolkit approach

Clarity of purpose andoutcome

Include options for deliveryand timing

Clear emphasis on actionplanning as ongoing andseparate activities

Worked examples ofexercises

More detail and clarifyexercises outcomes

Simplify language

Simplify/take out additionalinformation

Reconsider use of themesand KSF framework

More time to unpickknowledge and skills

Reconsider use of roleprofiling

Link outcomes toorganisational initiativesand provision

Proposed Impact

Ease of use

Relevance

Applicability

Maximise involvement

Contribute to servicedevelopment

Contribute toorganisational objectives

Ease of use

Relevance

Applicability

Maximise involvement

Contribute to servicedevelopment

Contribute toorganisational objectives

Changes made

ETNA Tool renamed Toolkit

Expanded introductorysections dealing withpurpose and outcomesidentified for each activity

Options for delivery andtiming including sampleworkshops and eventsequencing

Exercises renamed activities

Action planning shown asa discrete activity andaction plan ideas includedfor each of the otheractivities

Each activity has workedexamples, clear expectedoutcomes

Additional information andframeworks minimised toinclude themes and list ofresources

Role profiling taken out

Clear follow on and actionplanning ideas included tolink into organisationalprovision

26

27

5.2.1 Structure

The data showed that the ETNA Toolwould have greater value as a Toolkit.This would enable more flexibility inpractice and encourage services toengage with the Toolkit as a resource.The pilot illustrated that integratedservices had much to discuss, andthat unpicking knowledge and skills iscomplex and time consuming. Inaddition, pilot sites found theseparate exercises had sufficientsubstance to merit being held assingle events. Reframing the Tool as aToolkit encourages services to thinkabout different options for deliveryand timing of activities, for example,over a period of weeks or months. Inthis way more time could be spent onthe different activities enablingconsolidation of each of the exercisesthrough action planning beforemoving on.

The pilot sites also highlighted thatwhile they had much in common,services at different stages ofintegration would have differentconcerns. The ETNA Toolkit has aimedto address these issues by renamingthe exercises as activities andproviding more detail and clarificationof how each activity might be run.The pilot phase also indicated theimportance of the sequence ofactivities. For example, that althoughthe visioning exercise could form astand alone activity, the identifyingknowledge and skills exercisedepended on having reached ashared vision. The Toolkit now offersideas for how events might besequenced and presents sampleworkshops. Feedback from thefacilitators' workshop and the finalevaluation workshop highlighted theneed to clarify the purpose of theTool and its constituent componentsto aid delivery and to make explicitthe learning from the exercises inrelation to education and training

needs. These concerns have beenaddressed by expanding theintroductory sections and includingexpected outcomes for each of theactivities.

An important finding from the pilotphase was the need to make actionplanning more explicit and inparticular as a way of understandingthe fit between the activitiesundertaken as part of the ETNAprocess and ongoing servicedevelopment and organisationalobjectives. The ETNA Toolkit nowincludes action planning as a detailedactivity and illustrates action planningwithin other activities and as part ofcontinued development. Thesechanges aim to impact on all of thedevelopment criteria and in particularenabling its users to see itsapplicability and relevance as a needsanalysis resource that enhancesservice and organisationaldevelopment.

5.2.2 Content

Key recommendations from the dataconcerning the content of the Toolcontribute to the development of theTool as a Toolkit. For example, greaterdescription of the activities andexercises that might be used as partof activities, including workedexamples, help to illustrate howactivities can be used as separateevents and their relevance as part of asequence. The use of preparatorywork had been helpful for the PCT Apilot and a recommendation by PCT Bas a way of encouraging potentialparticipants to begin thinking aboutintegrated working beforehand. Thisissue is now addressed within theintroductory sections of the Toolkit.

An important recommendation wasthe need to simplify language andthis has been addressed throughoutthe document and aided byexpansion of detail and clarification

of expected outcomes for each of theactivities.

The pilot sites found that theidentifying knowledge and skills andthe role profiling exercises wereparticularly problematic to understandand portray, as was the additionalinformation intended for use withthem. The final evaluation workshopin particular highlighted theimportance of having the time andappropriate activity to unpickknowledge and skills. There have,therefore, been significant changesmade to the Toolkit to reflect theseissues. The identifying knowledge andskills activity has been clarified andexpanded using ideas from the pilotsites, for example, a staged approachto reaching a gap analysis. The Toolkitrefers to how facilitators may useframeworks such as the NHSKnowledge and Skills Framework andthe Shaping the Future themes(Howarth et al, 2004), but offersthese as resources rather thanprescribes their use. The role profilingexercise presented within the Toolprototype has been removed from theToolkit as this had been found to addlittle value to the ETNA process.However, role mapping and roleprofiling is recognised as a potentialaction planning exercise following onfrom the identifying knowledge andskills activity, and appropriateresources are provided for serviceswho wish to pursue this.

The pilot phase data showed thatservices are concerned about usinginterventions that are able to connectand link into existing organisationalinitiatives and provision. The Toolkithas addressed this by identifyingexpected outcomes of the activities sothat services can see how these fitwith their organisational objectivesand development activities. TheToolkit has also included actionplanning sections for each of the

28

activities to illustrate how outcomesfrom events can be taken forwardand developed further within existingorganisational provision.

5.3 LearningThe development and testing of anETNA Tool prototype has been a studythat has sought to produce a definedproduct, the ETNA Toolkit. However,as a qualitative research study it hasalso sought to gain learning in that:

'qualitative research is an effort tounderstand situations in theiruniqueness as part of a particularcontext and the interactions there…'(Patton, 1990:1)

This section presents the learninggained from the development of theETNA Toolkit including:

n Learning from the researchmethodology and methods;

n The learning gained concerningeducation and training needsanalysis and integrated health andsocial care.

5.3.1 Learning from Research Methodology and Methods

This research worked to threemethodological commitments ofcollaboration, learning and interactionon the basis that there is littledocumented understanding aboutintegrated health and social care(Howarth et al, 2004). It wastherefore considered an importantfeature of this 'Work Package' thatthose working within integratedhealth and social care were activeparticipants in the research process toinform and develop understandingthrough their views and practice. Thisapproach had value in that those whoparticipated took a stake in theresponsibility of the research andwere proactive in its continueddevelopment. The approach was alsovaluable in providing a forum for

shared knowledge betweenrepresentatives from a range of PCTs,tPCTs and Social Service Departments.This has led to the development ofnetworks amongst health and socialcare workers, between theresearchers and across the universitiesand health and social care services.Research into collaborative workingillustrates that decisions will be socio-political and moral in that ourmethodologies are value based(Toulemonde et al, 1998). Within thisperspective it can be argued that theresulting ETNA Toolkit is therefore aproduct which is clearly grounded inits context. However, it could also bedebated that as such the ETNA Toolkitmay serve to reinforce particularviews and ways of working.

Bryman (2001) notes that significantfeatures of qualitative research areflexibility and lack of structure, that isnot having presuppositions andhaving flexibility of method. Theinteractive and collaborative nature ofthis research was helpful in surfacingpresuppositions, for example, theextent to which our researchframeworks might suggest particularconcepts of integrated serviceprovision. The flexibility afforded bythe range of methods was also ofvalue in the collection of data. Forexample, during the pilot workshopsthe researchers were able to collectdata by observation, throughinteraction with the participantsduring exercises and by leadingstructured evaluation activities.However, the pilot sites found thatthe interactive nature of somemethods was at times distracting, forexample, stopping to reflect onactivities. The flexibility of approachwas also challenging and involved acontinual renegotiation of process asthe research progressed. This includedmanaging the cancellation of a pilotsite at a late stage, and Reference

Group members not always beingable to attend meetings due to otherpriorities.

5.3.2 Learning about Education and Training Needs Analysis and Integrated Health and Social Care

Participants felt they had gainedlearning from being involved with thedevelopment of the ETNA Toolkit. Inparticular, the pilot sites found thatthe pilot of the prototype offeredthem an opportunity to hear theirteam's views and opinions.Representatives participating in theReference Group meetings found thesharing of views and knowledge ofparticular value within the networksformed across representativeorganisations and universities.

At a broader level the development ofthe ETNA Toolkit has illustrated thatworking with education and trainingneeds in integrated health and socialcare settings is complex and hasimpact beyond the uncovering ofneeds. This work offered thefollowing insights:

n Working together and workingas an integrated service. Thefinal evaluation workshop revealedan acknowledged differencebetween working together andworking as an integrated service,that suggests the needs requiredfor working as an integratedservice may be different. The pilotsites and the reference groupmembers thought that there wasvalue in working with a process tohelp services identify what it isthat makes them an integratedservice and what this may requirerather than a joint working serviceor one that works together. Thiswas illustrated by PCT A who hadmany examples of how theyworked well together, for example

29

regular team meetings. However,working in an integrated way wasviewed as moving beyondrecognition of each others' rolesto involve deeper attention to theinteraction and enactment ofservice roles. A simple example ofthis was given of when a socialservices worker goes into a homeand sees that the person couldbenefit from a bath aid. They letthe Occupational Therapist knowwho then does not go and repeatthe basic assessment, as maytraditionally happen, but providesthe bath aid on the basis of thegiven assessment. Such exampleshighlight the need to specify skillsand knowledge required forintegrated working and whatthese skills and knowledge mightinvolve.

n Unpicking knowledge andskills. Development of the Toolkitfound that it can be problematicto get people to identify what it isthey know and what they can do(knowledge and skills) and to talkabout this outside of theirprofessional setting. Manypractitioners are very experiencedand have often reached a stage ofunconscious competence wherethey are no longer consciouslyaware of their skills andknowledge. There was somerecognition that during the Tooldevelopment process theresearchers may have assumedgreater levels of consciouscompetence, or the ease at whichpeople can identify and relateknowledge and skills. The pilothas illustrated that in workingwith a range of professions thiscan take time and is complex asknowledge and skills are oftenvaried, overlapping and multi-purpose.

n Importance of structureddialogue. An important aspect ofthe research, similar to findings byBlackler and Kennedy (2004), wasthe value that participantsthroughout the development ofthe ETNA Toolkit placed on theopportunity to interact with theirpeers within a structured format.This was found to be beneficialnot only in terms of networkingbut also in gaining understandingof how other organisations andservices work on the particularissue of identifying education andtraining needs. Particular learningfrom the provision of structureddialogue, reinforced by the pilotphase, was the importance ofservices spending enough time onreaching a shared understandingof their current situation withinany ETNA process, beforeexploring development needs.

n Working with process. The pilotphase illustrated that a processcentred approach to educationand training needs analysis wasimportant in enabling services tosurface and articulate needs ofrelevance to them in their context.The focus on process broughtmuch value to the sites inestablishing and developingdialogue but this also raised issuesfor consideration. The pilot phasefound that the value of a processled education and training needsanalysis relies significantly uponthe facilitation of the process and,therefore, facilitator skill. Thisplaces the facilitator(s) in a crucialrole and assumes appropriatefacilitation skills and sufficientbackground knowledge of theservice and team to makeexercises relevant and to developdiscussion. The pilot sites used forthis research saw the ETNA Toolpilot phase as a positive

developmental opportunity. Theskill required to work within apositive environment raised theissue of the importance of havingsufficient skill to be able to workwith teams or services that wereexperiencing difficulties andconflict.

n Role of Education and TrainingNeeds Analysis. Participants inthis research found thatconceptualising needs forintegrated health and social carewas a context dependant activity,and that this called for a model ofeducation and training needsanalysis that enables needs toemerge rather than prescribesneeds within a given framework.Reference Group members andpilot sites found that this researchgave them the time to reflect onhow they typically deal witheducation and training needsanalysis. Debate during thedevelopment of the Toolkitrevealed that many organisationshave a variety of ways in workingwith this, from personaldevelopment planning to teamaway days. The research indicatedthat education and training needsanalysis tended to be aimed atparticular groupings, for example,education and training needsanalysis for social workers ornurses rather than as a teamconcern. It was felt that broaderlearning and developmentalaspects that might be fosteredthrough collective process-ledinterventions are often forfeited infavour of instrumental methodsand tools that focus on individualjob and role competencies. Whileparticipants in the development ofthe Toolkit showed an enthusiasmand stressed a need for educationand training needs analysis thatattended to integrated health and

30

social care at a service and teamlevel, they recognised that withinthe broader scheme of change inthe NHS this was not necessarilyregarded as a priority. This wasunderlined by the pilot phase ofthis research that indicated thesustainability and importance ofeducation and training needsanalysis as part of a widernetwork of developmentalprovision that must have relevanceand linkage to existingorganisational and servicedevelopment initiatives.

31

Chapter Six: The Evidence and Implications for Future Educationand Training Needs Analysis 6.1 IntroductionThis concluding chapter reviews theforms of evidence that have informedthe development of the ETNA Toolkit.In particular, it seeks to explore howevidence has been drawn from avariety of sources and refashionedthrough iterative developmentalprocesses involving the users ofevidence to derive a prototype Tooland a final product in the form of aToolkit for education and trainingneeds analysis. This does not reflect atraditional model of knowledgetransfer from the academy toconsumers of knowledge whereresearch findings are implemented(Sebba, 2004). Rather, it reflects amore complex interaction betweenhealth and social care organisations;university researchers; project partnerswithin a wider project team; serviceusers; and a wider context of policydevelopment that develops theknowledge of these participants inthe research process. As such areview of the evidence requires anacknowledgement of the dynamicrelationship between practice,evidence and policy that shape thepragmatics of research on the onehand and of education and trainingneeds analysis for servicedevelopment on the other.

6.2 Relationships between Policy, Practice and Evidence

The relationships between policy,practice and evidence are complexand potentially contentious andcannot be fully explored here.However, the development andtesting of the ETNA Toolkit isinevitably implicated in theserelationships. In concluding ouraccount of this project we seek tomake more explicit the role ofevidence and policy in relation to thedevelopment of the Toolkit as a

resource for practitioners and servicedevelopment. The Project, withinwhich this research is situated,recognises that notions of practice,evidence, policy, education andtraining carry with them certainassumptions, for example, in terms ofagency. The literature review byHowarth et al, Halics. (2004)demonstrates that these terms arenot self-evident, are complex and mayhave different meanings for differentindividuals, organisations andcommunities.

Figure 4: Relationships between policy, practice and evidence

These complexities and interpretationsare illustrated through thedevelopment of the Toolkit and inparticular the understanding of needsas debated in Chapter 3. Inrecognition of these complexities thischapter acknowledges that adiscussion of the relationshipsbetween policy, practice and evidenceis framed by the context of theresearch and its inherentassumptions.

One way of tracing the relationshipsbetween policy, practice and evidence

is illustrated in Figure 4 and discussedbelow:

From policy-led practice topractice based evidence

The initial impulse for the Shapingthe Future Project reflects recognitionby the collaborating universities andtheir sponsor that changes in healthand social policy were likely to have amajor impact upon service deliverythrough increasing integration ofservices in health and social care. Asystematic review of the literature'took account of the importance andinterconnectedness of policy, practice,population and workforce needswithin an integrated health and socialcare service' (Howarth et al 2004: 4).The Project itself is policy-led andrecognises policy-led development ofpractice in service delivery andassociated education and training ofthe workforce. The aim of the Projectaccepts as a premise the integrationof health and social care, andvalidates its purpose, through itsdefinition of health and social care as'care that is determined by

32

partnerships between health andsocial care agencies and users/carersfor the health and well being of the(local) community.' Building upon thispremise, the Project aims to find theevidence for education and trainingto deliver such integrated services.Thus, the Project moves from arationale in policy-led practice to theaim to secure evidence basedpractice.

From practice based evidence toevidence based practice

The research aims to fulfil this aim tosecure evidence based practice byutilising practice based evidence.Although the development of theToolkit made use of the existingevidence base for training needsanalysis, the selection, evaluation andutilisation of this evidence was guidedby the pragmatics of on-goingdevelopment of policy and theopinions and experiences ofpractitioners. This led to questioningthe assumption that needs analysiswas not taking place owing to thelack of a tool rather than theinfluence of competing prioritieswithin organisations. The publicationof the draft Knowledge and SkillsFramework in March 2003 and theimplementation of Agenda forChange concentrated the attention ofthe researchers and Reference Groupupon the need to link the Tool to theKSF so as to make virtue out of thenecessity for organisations to makeuse of the KSF. Hence, the ETNA Toolbecame a Toolkit, wherein 'evidence'becomes transformed into 'resources'or 'tools' combined in a 'kit' to linkthe KSF to the identification oftraining and development needs. Inthis way the Project exemplifiespartnership between practitioners andresearchers engaged in 'developmentand research' rather than 'researchand development': that is, practicebased evidence drives the research

process. Sebba (2004) sums up suchactivity as:

An interactive approach to producing,disseminating and using newknowledge which requires atransformative process to overcomethe hazards of transfer andapplication … Successful knowledgetransfer does not guarantee effectiveapplication due to, for example, lackof opportunity or resources,adherence to deeply held beliefs ordifficulty in translating theoreticalknowledge into practice. (Sebba,2004: 40)

Thus the ETNA Toolkit, having beenpiloted and refined though acollaborative process withpractitioners and the Reference Groupis a 'product' derived from practicebased evidence that may be used asevidence based practice.

From evidence based practice toevidence based policy

The potential for feedback fromevidence based practice into evidencebased policy emerged through thedevelopment of the ETNA Toolkit.Notwithstanding the seemingimperative of the use of the KSF, itsterminology was at best unhelpful forETNA workshop participants. AsSebba (2004:40) points out, evidencebased policy that assumes a linearrelationship between research and itsusers may be ineffective in thetransfer of knowledge owing to 'theway it is expressed or the receptivityof the recipient'. Within thedevelopment of the ETNA Toolkitparticipation of Reference Groupmembers and the pilot sites sensitisedthe researchers to this issue for bothservice users, carers and employees.The adaptation of the 'field of words'technique (Cowley and Houston,2003) for needs assessment provideda way to facilitate participants toarticulate in their own terms the skills

and knowledge that they bring tohealth and social care as well asidentifying learning needs. Therefore,the Toolkit while policy-led in itsinception provides opportunities forevidence based practice and practicebased evidence to contribute to theevidence base shaping theinterpretation and implementation ofpolicy in service settings.

6.3 Implications for Research and Education andTraining Needs Analysis

An exploration of the relationshipsbetween policy, practice and evidencehas implications for both educationand training need analysis andresearch itself. In this study theconduct of the research and thepractice of ETNA for servicedevelopment both share a commongoverning rationality of 'integration',melding policy, practice and research.The impulse for ETNA derives fromthe notion of 'integration' as a policyimperative. Likewise the research itselfhas accepted this governingrationality with respect to both itssubject matter and its conduct. Policy,practice and evidence have been'integrated', arguably transgressingorthodox views of validity wherebythe authority of research lies in thehierarchical application of the findingsderived from evidence to practiceand/or policy. Stronach and MacLure(1997) point out a trend ineducational evaluation research tomake reference to canons of researchorthodoxies as guarantors ofauthority for the producers andconsumers of research. However, atthe same time this trend adoptsincreasingly pragmatic 'truncated'forms of research at the service ofprogrammes of 'reform' such as'modernisation', 'service redesign' or'integration' that provide therationale for interventions such aseducation and training needs analysis.

33

The ways in which relationshipsbetween policy, practice and evidenceare played out have implications forhow the governing rationality ofresearch, and the practice it purportsto investigate or develop, is mademore explicit, sustained orattenuated.

The themes 'considered essentialrequirements for integrated healthand social care services' (Howarth etal, 2004) derived from the systematicreview of literature, convey anauthoritative framework foreducation and training needs analysis.This can be contrasted to thepragmatics of tool developmentwhereby the development of theETNA Toolkit recognised policyimperatives and simultaneouslydeflected from them. For example,taking into account the NHSKnowledge and Skills Framework andat the same time remaining apartfrom its implicit claim to codify all theskills and knowledge that any workermight need to be able to display. Thedevelopment, piloting and refinementof the ETNA Toolkit has placed intothe hands of potential users resourcesthat are, on the one hand, moremodest than might have beenenvisaged by a 'tool' that, by virtue ofits scientific development could beguaranteed to 'do the job'. On theother hand, these same users, have aset of tools that they can select,combine and deploy in ways thatoffer more opportunity to determinewhat the job in hand actually is, aswell as to accomplish it.

Although the point of departure forthe development of the Toolkit wasinfluenced, if not determined, bypolicy, the use of the Toolkit supportsa varied interpretation of policy inpractice in terms of servicedevelopment, needs analysis andaction planning. In this respect theresearch reflects self critical and

realistic (pragmatic) contemporaryevaluation research characterised byhybridity; transgressive validity; andnegotiation or dialogue betweenresearchers and respondents(Stronach and MacLure, 1997: 109-111).

Hybridity, in this case, concerns theblending of tool development andevaluation research, exemplifying'development and research' ratherthan 'research and development'(Sebba, 2004: 40). It is also evident inthe combination of methods withinthe work reported here and withinthe wider Shaping the Future Project;in the subject matter, whereby diverseparticipants in service delivery areengaged in needs analysis; and finallyin the combination and customisationof existing 'tools' as resources byusers of the Toolkit.

Transgressive validity describesresearch that, rather than seeking to'reproduce' an ostensibly stablereality, recognises reality as a flux ofpolicy, practice and evidence. As aconcept in this context, transgressivevalidity is evident in the fullacknowledgement of policy'imperatives' that are sometimesincoherent or contradictory. Researchthat intervenes in (or transgresses)this reality offers new possibilities forlearning, co-creating new knowledgeand changing practice on behalf ofparticipants and users of the research.Both the research and the ETNAToolkit, through an emphasis onparticipatory methods and 'process',recognise that policy implementationin practice involves interpretation asmuch as application. For example,while processes of integration arepresented by policy as a given, withinthe use of the Toolkit the vision ofwhat integration might be is not. Asa further example, it can be notedthat while the KSF is obligatory forthe NHS it does not (at least as yet)

apply to non NHS participantsengaged in health and social care.Researchers and participants in thedevelopment of the Toolkit sought tofind ways of working with the KSFwhile also finding language andpractices that provide alternatives toits direct application in needs analysisactivities. The validity of the Toolkit isenhanced by the capacity to workwith and against the realities ofincoherence and contradiction, henceits validity can be deemed'transgressive'.

Negotiation and dialogue concernsthe methodological commitment toparticipatory methods. Negotiationand dialogue are evident in theengagement of participantsthroughout the development andpilot phases of the study. Thisrecognises shifting levels of influenceof policy, practice and evidencethroughout the process of theconduct of the research and in needsanalysis itself. The use of the ETNAToolkit facilitates the local constitutionof needs as a negotiated process (seechapter 3) through the use of theToolkit whereby a hybrid resourceenhances the validity of needsanalysis by virtue of both recognisingand at times transgressing the'givens' (Wells, 2004) ofcontemporary policy for serviceintegration.

6.4 SummaryThe development and testing of anEducation and Training Needs AnalysisToolkit for integrated health andsocial care forms part of the widerShaping the Future Project thatengaged seven universities in theNorth West of England in acollaborative partnership. The aim ofthe research partnership is to identifythe evidence base for delivery ofintegrated health and social care; theskills and knowledge required todeliver this care, together with the

34

current and future education andtraining needs of the North West ofEngland Primary Care Workforce.

The development of the ETNA Toolkitadopted methodologicalcommitments of collaboration,learning and interaction that arehighly congruent with the overall aimand approach of the Shaping theFuture Project and the Project'sdefinition of health and social care as:

'care that is determined bypartnerships between health andsocial care agencies and users/carersfor the health and well being of the(local) community.'

An ETNA Tool prototype wasdeveloped under the guidance of anexpert Reference Group and madeuse of resources available in thepublic domain. The appraisal of theseresources was undertaken in the lightof evolving policy affecting thecontext of service development inhealth and social care. This wasinformed by the Reference Group andthe findings of the systematic reviewof the literature being undertaken byHowarth et al (2004) within the widerShaping the Future Project. Thetesting and evaluation of the ETNATool prototype was also undertakenwith the Reference Group culminatingin an amended ETNA Toolkit. Thisaccount of the development of theToolkit concludes by noting thedynamic and complex relationshipbetween practice, evidence and policythat shapes the pragmatics ofresearch on the one hand and ofeducation and training needs analysisfor service development on the other.The Toolkit is designed in such a waythat participants may use it as a set oftested and adaptable resources forcollaboration, learning and interactionaimed at the further development ofcare that is determined bypartnerships between health andsocial care agencies and users/carers

for the health and well being of localcommunities.

6.5 ConclusionThe development of the ETNA Toolkithas illustrated that education andtraining needs analysis for integratedhealth and social care is importantbut competes with other priorities. Assuch it must therefore be seen as partof a wider strategic development towhich it contributes. This calls foreducation and training needs analysisthat has relevance to local contextand recognises that needs vary fromservice to service and locale to locale.Therefore, it is important thateducation and training needs analysisenables purposeful dialogue thatfacilitates the unpicking andstructuring of the complexity ofknowledge and skills and aids thecreation of a local, sustainable andachievable vision through theconceptualisation of needsappropriate and relevant to aparticular service.

This research has demonstrated thatunderstanding and analysingeducation and training needs forintegrated health and social care iscomplex. Education and trainingneeds analysis may, therefore, supportthe identification of knowledge andskills for progressive integrationbeyond joint working. This learningsuggests an emergent model ofeducation and training needs analysisbased on process led activities thatpromote the capacity to articulate,achieve and sustain a context-relevantvision of integrated service provision.

The production of the ETNA Toolkitreflects collaboration, learning andinteraction between health and socialcare organisations; universityresearchers; project partners within awider project team; service users; anda wider context of policydevelopment that develops the

knowledge of participants in theresearch process. Developing theToolkit has highlighted the interplayof policy, practice and evidence inthat it is informed by policy,developed as a product of practicebased evidence that in turn seeks toinform policy. As such this researchsuggests that this kind ofintervention, although often policyled, is very much about co-creation ofevidence based practice that benefitsfrom the participation of practitionersand researchers in furthering practiceand knowledge. The co-creation ofpractice may therefore work withinpolicy while furthering newunderstandings of policy in action.

Exploring the relationships of policy,practice and evidence in the contextof this research has highlighted thatthis research is in itself an illustrationof the tensions and challengesinherent in working within policywhile seeking to remain practicebased. The methodological approachfor this research and the developmentof an emergent process-led ETNAToolkit has enabled these tensionsand challenges to be made explicit,debated and interpreted at a locallevel. As such this workacknowledges a need for researchand education and training needsanalysis that offers ways in whichsuch tensions and challenges mightbe mapped and understood, and thatenables contributions to developingknowledge, policy and practice.

35

Appendix 1: Education and Training Needs Analysis (ETNA) forintegrated health and social care in the contextof the Shaping the Future Project

Identify agencies

Partnership capabilities –WP3

Benchmark; NatPactpartnership competencies;the 'working partnership'(HDA); 'smarterpartnerships'.

Identify staff \ workers –WP5

Are they involved? (workingtogether: staff involvement– a self assessment tool)Views?Levels in the organisation?

Identify actual andpotential users and carersWP6

PPI strategyLevel of participation?

What/who is thecommunity?

StrategiesHiMpLocal strategic partnership(LSP)Local delivery plan (LDP)

Past

Perquisites\inputs

Education and trainingneeds analysis (ETNA)

ETNA process

ETNA toolkit

Vision of integrated healthand social care

n What do they/we knowand do?

n What do they/we need toknow and do?

n At what level?

Workforce development

Present

Who? Present workforceHow many? Who have wenow?Function? What do they do?Activity analysis

Process

Educational outcomes of provision – WP4

Profile Assessment Learning needs

Generic Gap analysis PDP'scompetencies; Learning plansLocal Cpd commissionscompetencies

Continuing inclusion of users and carers

Service development

Future

Function: what should they be doing?

What kind? Future skills

Where/how many? Roles

Future

Outputs

WP = 'Work Package' from Shaping the Future Project

36

Appendix 2: Further Resources to support Education and Training Needs Resources

Department of Health Knowledge and Skills Frameworkand Development Review (Department of Health, 2004)

See web pages from the Department of Health web sitehttp://www.dh.gov.uk/Home/fs/en

Markwell S, Watson J, Speller V, Platt S and Younger T(2003) The working partnership. London. HealthDevelopment Agency

http://www.hda-online.org.uk/documents/working_partnership_1.pdf

See also Health Action websitehttp://www.healthaction.nhs.uk/Visit pages onPartnership development

HDA Public Health Skills Audit

Burke, S., Meyrick, J. and Speller, V. (2001) Public HealthSkills Audit: Research Report. Health DevelopmentAgency. London

Available from http://www.publichealth.nice.org.uk/

Publications available on linehttp://www.hda-online.org.uk/search/results.asp

On line toolhttp://www.phskills.net/

National Occupational Standards in Health and SocialCarehttp://www.skillsforhealth.org.uk/

Smarter Partnershipshttp://www.lgpartnerships.com/

Main features

Linked to 'Agenda forChange'

A collection of tools tounderpin partnershipdevelopment

Completed on-line or usingpaper based work book,with option of facilitatedworkshops (guideavailable).

ETNA tool has adaptedsome aspects of process.

Functional analysis andcompetencies – related tovocational awards

A range of tools to assessskills and knowledge forpartnership working withsuggested educational\training activities

Comments

Partnership sectioncorresponds to Shapingthe Future Projectdefinition of integratedhealth and social care.

Links to learning outcomesand organisational levels

Based on VeronaBenchmark and developedby the HealthDevelopment Agency

Developed by HDAthrough research projectand now managed byJohn Moores University asan on line resource.

Widening range ofOccupational Standards

37

Resources

QUILT

http://www.quilt.org/Home/ptool.html

Working Together: Staff involvement – a self assessmenttool

Tool and Action Plan both available from

http://www.dh.gov.uk/Home/fs/en

NatPaCT organisational competency framework.

http://www.natpact.nhs.uk/

The partnership competencies

http://www.natpact.nhs.uk/downloads/newcf/5.pdf

Sainsbury Centre Model for the capable practitioner.

The Sainsbury Centre for Mental Health (2001) The capable practitioner. The Practice Development &Training Section, The Sainsbury Centre for Mental Health

http://www.scmh.org.uk/

Modernisation Agency: Changing the work force tool kitfor local change

http://www.modern.nhs.uk/home/default.asp?site_id=58

Modernisation Agency's NHS Improvement Leaders'Guides

Main features

A set of tools to supportpartnership development

Available on-line,completed as a paperbased activity based on 7standards relevant toorganisational developmentfor service planning anddelivery

A very extensive, interactiveweb based resource undercontinuous development,linked to the modernisationagency.Includes selfassessment guides tocompetencies at variouslevels of specificity

Developed in the context ofmental health

A series of guides tosupport leadership andchange management,including:

n Setting up acollaborativeprogramme;

n Managing the humandimensions ofchange.

Comments

USA resource for earlyyears context of integratedservices

A generic tool focussingon organisationalcapability for servicedevelopment necessary for(but not confined) tointegrated health andsocial care

Specific focus on primarycare and associated areasof activity includingpartnership, workforcedevelopment, education,training and research aswell as specific serviceareas and professionalgroups

Most relevant at theStrategic level

Capable of being appliedto a variety of servicecontexts

Applicable to serviceredesign and parallelcurriculum development

38

Resources

Making Health Scrutiny Work: The Toolkit

http://www.dhn.org.uk/

Health Education Board for Scotland (1995)

Devising methods to assess training needs of healthpromoters in Scottish area health boards

http://www.hebs.org.uk

System-Linked Research Unit on Health and SocialService Utilization, based at McMaster University,Ontario, Canada

http://www.fhs.mcmaster.ca/slru/home.htm

National Primary Care Development Team

http://www.npdt.org

Integrated Care Network

http://www.integratedcarenetwork.gov.uk/homepage.php

The King's Fund,London.http://www.kingsfund.org.uk/PDF/partner.pdf

Main features

Produced by theDemocratic Health Networkto assist local governmentto fulfil its obligations for'Health scrutiny' andpartnership working

Detailed research report.

Provides details of researchprogrammes and resourcesrelevant to integratedservice provision

Information on'Collaborative'methodology

Range of tools, resourcesand information

Extensive publications andresearch reports

Comments

Contains check lists, casestudies and summaryboxes

Methods and findingsapplicable acrossprofessional andorganisational boundaries

See references onpartnership andintegration

Web sites accessed 20 April 2005. The authors cannot accept responsibility for the contents or continued availability ofthe web sites listed.

39

References

Blackler F and Kennedy A (2004) TheDesign and Evaluation of a LeadershipProgramme for Experienced ChiefExecutives from the Public SectorManagement Learning. 35 (2) 181 –203

Bradshaw J (1994) Theconceptualisation and measurementof need: a social policy perspective. InJ Popay and G Williams (Eds)Researching the people's health.(Chapter 3) London. Routledge.

Bryman A (2001) Social ResearchMethods. Oxford. Oxford UniversityPress.

Burke, S. Meyrick J. and Speller V.(2001) Public Health Skills Audit:Research Report. London. HealthDevelopment Agency.

Changing the workforce tool kit forlocal change, ModernisationAgency:http://www.modern.nhs.uk/home/default.asp?site_id=58Accessed20 April, 2005.

Cowley S and Houston A (2003) Astructured health needs assessmenttool: acceptability and effectivenessfor health visiting. Journal ofAdvanced Nursing 43 (1) 82 – 92

Department of Health (1998)Modernising social services:promoting independence, improvingprotection, raising standards. London.Department of Health. Cm 4169

Department of Health (2003) TheNHS Knowledge and Skills Framework(KSF) and Development ReviewGuidance – Working Draft. London.Department of Health

Department of Health (2004) TheNHS Knowledge and SkillsFramework(NHS KSF) andDevelopment Review Process.London. Department of Health.

Easterby-Smith M (1994) EvaluatingManagement Development, Trainingand Education 2nd edition. London.Gower.

Gregory A (2000) Problematizingparticipation: A critical review ofapproaches to participation inevaluation theory. Evaluation. 6 (2)179 – 199

Hart E and Bond M (1997) ActionResearch for Health and Social Care: aguide to practice. Buckingham. OpenUniversity Press.

Health Education Board for Scotland(1995) Devising methods to assesstraining needs of health promoters inScottish area health boards. HealthEducation Board for Scotland.http://www.hebs.org.uk Accessed 20April, 2005.

Howarth M, Grant M and Holland K(2004) Finding the Evidence forEducation & Training to deliverIntegrated Health & Social Care: ASystematic Review of the LiteratureShaping the Future for Primary CareEducation & Training Project.University of Salford

Mitcheson J and Cowley S (2003)Empowerment or control? An analysisof the extent to which clientparticipation is enabled during healthvisitor/client interactions using astructured health needs assessmenttool. International Journal of NursingStudies 40: 413 – 426

Nettleton R and Stead V (2005)Education and Training Needs Analysis(ETNA) Toolkit: A resource kit andusers'guide Shaping the Future forPrimary Care Education and TrainingProject. University of Salford.

Owen J M and Lambert F C (1995)Roles for evaluation in LearningOrganizations. Evaluation 1 (2) 237 –250

Patton M Q (1990) QualitativeEvaluation and Research Methods.2nd Edition. Newbury Park CA. Sage.

Pawson R and Tilley N (1997) RealisticEvaluation. London. Sage.

Preskill H and Torres R T (1999)Evaluative Enquiry for Learning inOrganizations. Thousand Oaks, CA.Sage.

Sebba J (2004) Developing evidence-informed policy and practice ineducation. In G Thomas and R Pring(Eds) Evidence based practice ineducation (Chapter 3). Maidenhead.OUP/McGraw-Hill.

Stead V, Mort M and Davies J (2001)Theory Generation and PracticeImprovement: a mental health serviceperspective. Educational ActionResearch. 9 (1) 61 – 77

Stronach I and MacLure M (1997)Educational research undone: thepostmodern embrace. Buckingham.Open University Press.

The Sainsbury Centre for MentalHealth (2001) The capablepractitioner. The PracticeDevelopment & Training Section, TheSainsbury Centre for Mental Health.

Torbert W. (1981) Why educationalresearch has been so uneducational?In P. Reason and J. Rowan (eds)Human Inquiry: a sourcebook of newparadigm research. Chichester. WileySons Ltd.

Toulemonde J, Fontaine C, Laudren Eand Vincke P (1998) Evaluation inpartnership : practical suggestions forimproving their quality. Evaluation 4(2) 171 – 188.

Wells S (2004) Improvisation: thedrama of Christian ethics. London.SPCK.

40

For information about 'Agenda forChange' see the following web sites(accessed 18 June, 2005):

For information about 'Agenda forChange' see the following web sites(accessed 18 June, 2005):

http://www.dh.gov.uk/PolicyAndGuidance/HumanResourcesAndTraining/ModernisingPay/AgendaForChange/fs/en

http://www.content.modern.nhs.uk/cmsWISE/Workforce+Themes/Retaining_and_Developing_Staff/PayandReward/ImplementingAgendaforChange/Implementing+Agenda+for+Change.htm