Agenda for Change does not get the green light from the voting members of the unions, the whole plan for NHS modernisation is in jeopardy. For nurses, Agenda for Change is about a new pay and career structure, but for the government it is an important building block in creating a 'modern' NHS. Agenda for Change is not a done deal. Even so, it is already regarded as a key part of the overall plan to change the way the NHS.

The Scottish Executive has published the action plan resulting from last November's convention on nurse recruitment and retention. Backed by initial funding of £1.5 million, the plan sets out ways to improve the status and work experiences of Scotland's 30,000 NHS nurses.

This paper discusses the reasons for skill mix among health workers being important for health systems. It examines the evidence base (identifying its limitations), summarizes the main findings from a literature review, and highlights the evidence on skill mix that is available to inform health system managers, health professionals, health policy-makers and other stakeholders. Many published studies are merely descriptive accounts or have methodological weaknesses. With few exceptions, the published analytical studies were undertaken in the USA, and the findings may not be relevant to other health systems. The results from even the most rigorous of studies cannot necessarily be applied to a different setting. This reflects the basis on which skill mix should be examined--identifying the care needs of a specific patient population and using these to determine the required skills of staff. It is therefore not possible to prescribe in detail a "universal" ideal mix of health personnel. With these limitations in mind, the paper examines two main areas in which investigating current evidence can make a significant contribution to a better understanding of skill mix. For the mix of nursing staff, the evidence suggests that increased use of less qualified staff will not be effective in all situations, although in some cases increased use of care assistants has led to greater organizational effectiveness. Evidence on the doctor-nurse overlap indicates that there is unrealized scope in many systems for extending the use of nursing staff. The effectiveness of different skill mixes across other groups of health workers and professions, and the associated issue of developing new roles remain relatively unexplored.

We have reached the end of the beginning of Agenda for Change. Soon nurses in the early implementer sites will become involved in the day-to-day realities of implementing a new pay system. What next? It makes sense to look at what has been happening in some other sectors of public service to pick up useful pointers.

Changing skill mix is often identified as a potential solution to health services staffing and resourcing problems, or is related to health sector reform. This paper discusses what is meant by skill mix, provides a typology of the different approaches to assessing skill mix and examines, by means of case studies, the contextual, political, social and economic factors that play a part in determining skill mix. These factors are examined in relation to three factors: the reasons (or drivers) for examining skill mix; the impact of contextual constraints; and the effect of varying spans of managerial control. Case studies conducted in Costa Rica, Finland, Mexico, the UK and the USA are used to explore the reality of assessing skill in different contexts and health care settings. We argue that, although skill mix may be a universal challenge, it is not a challenge that all managers or health professionals can meet in the same way, or with the same resources. Context can have a significant effect on the ability of health service managers to assess and change skill mix. The key determinant is the extent to which these factors are in the locus of control of management nationally, regionally, or locally, within different countries. We emphasise the need to evaluate the problem and examine the context, before deciding if a change in skill mix is the answer. The local managerial span of control and degree of organisational flexibility will be major factors in determining the likely impact of any attempts to change skill mix. Before embarking on a skill mix review, any organisation should ask itself the question: 'If changing skill mix is the answer, what is the question?'

CRISIS, WHAT crisis? After a long period of apparently being immune from the nurse shortages hitting south of the border, Scotland is now having to face up to and deal with its own recruitment difficulties.

A mandatory minimum nurse to patient ratio improves outcomes. Linda Aiken reports on her research

The publication of the NHS Plan for England has highlighted how dependent we have become on international recruitment to fill nursing vacancies. To meet the ambitious service growth targets set out in the plan, the NHS will require a quoted 20,000 more nurses. In the short term, at least, we cannot rely on our own education system and labour market to meet that need.

Working hours in the NHS have reduced over the years, but 'hidden' overtime is still subsidising the system and nurses are paying the price

The UK is very reliant on physiotherapists who trained overseas, who now represent almost a third of new entrants. Australia is the main source of overseas-trained physiotherapists. It the UK is to increase recruitment of physiotherapists from overseas, ethical considerations mean it should focus on the EU, the US and Australasia and not developing countries.

A labour market survey reveals a mismatch between the number of nurses in the NHS and the thousands needed to achieve the NHS Plan. James Buchan reports

The government has set specific goals for NHS employers to improve their performance. Here James Buchan questions whether it will hit the mark and below Stephen Griffin looks at the improving working lives standard

Special duty payments are set to be a major sticking point in the new NHS pay discussions. James Buchan asks what the alternatives are

The number of overseas nurses coming to the UK has risen 48 per cent in 12 months. The bulk of the increase has come from non-EU countries such as South Africa, Australia, the Philippines, New Zealand and the West Indies. This trend flies in the face of Department of Health guidance that urged trusts not to recruit from developing countries which were experiencing shortages of their own. Overseas nurses now account for almost one third of those working in inner London and 3.5 per cent of the nursing workforce in England.

The objective of the paper is to assess the human resource (HR) dimension of the National Health Service (NHS) reforms in the United Kingdom, and to highlight lessons for the health systems of countries undergoing reform or restructuring. Health sector reform in many countries in the 1980s and 1990s has focused on structural change, cost containment, the introduction of market mechanisms and consumer choice. This focus has inevitably challenged the ways that health professionals and other staff are employed and deployed. The methods used to manage human resources in health care may also in themselves be a major constraint or facilitator in achieving the objectives of health sector reform. The impact on the HR function of the NHS reforms is assessed in the paper by examining three central requirements of the HR function: to maintain effective staffing levels and skill mix; to establish appropriate employee relations policy and procedures; and to be involved in pay determination. The paper concludes that the most significant changes which have occurred as result of the NHS reforms have been in staffing change and organizational culture, and the individual attitudes of NHS management and staff. Attempts to alter methods of conducting employee relations and determining pay and conditions of employment have been less successful. However, an overall approach to HR management, which would have been unthinkable in the pre-reform NHS, is now accepted, albeit grudgingly by some, as the way forward. In general, the changes in the NHS HR function can be characterized as a partially successful attempt to adopt private sector HR management techniques to meet the challenges of public sector reform.

This article examines key aspects of change in European nursing labour markets, and highlights an integrated policy framework intended to improve nurse recruitment, retention and utilization in European health care. Health care is labour intensive. Staffing costs are often a major focus of the health sector. There is a tendency for staffing to be regarded as part of the 'problem' of cost containment, and staffing costs are often a major focus of health sector reform. This report argues that it is more appropriate to regard staffing in general, and nurses in particular, as part of the solution to improving quality, access and cost of care. The major elements in nurse workforce planning are discussed, and the need for planning to be integrated with service delivery is emphasized. With projected increases in the demand for healthcare, and concern about staff shortages, policy attention across Europe and in other countries must focus on improving the methods of recruiting, retaining and utilizing nursing resources. A policy-based framework for sustained improvement is presented, based on five areas of action: improve 'conventional' recruitment; improve recruitment from 'non-conventional' sources; identify and apply incentives to improve staff retention and motivation; improve staff deployment; and improve utilization/skill mix.

We are currently clawing our r way out of the depths of the ' worst nursing shortage in recent memory. A lot of tax- ' payers' money has been targeted at the problem over the past two years. Government plans for 'modernisation' of the NHS make it clear that we need more staff. How did we get into the problem of shortages in the first place, and what should we learn for the future?

Flexibility once meant insecurity and unpopular shift patterns imposed by management, but a partnership approach can also make it work for staff

The Budget may have promised more health service funding, but improvements will depend on how the money is used