 Felly, refinnwyd aethlwyddiant yn 2018. Felly, ddim ei rhywbeth o ddim yn rhaid i'ch bod ni'n hofyn rhoi newid ei Hoon sydd yn ddechrau ar gyfer hynny, ond mae'n yn eich hanfod i ddweithio ddefnyddoedd o ni, dda i'n rhaid i'ch bod ni'n dweithio ar gyfer hollfyrwch yng nghymru. I apologize for receiving that this morning from Miles Briggs, the first item on our agenda is the final evidence session on stage one of the Health and Care Staffing Scotland ond yw i gael i'r ffordd nifer o gyllid y cyfnodau ar gyfer, mae gennymau i'r cyffredinol yng nghymru yn FfioNama Queen, gerysgwylliant yn FfioNama Queen, gan gyffredinol ynghylch yn Lluys Kau, gan gyffredinol ynghylch yn y Gymdeithasol Llywodraeth, gan gyffredinol Eilsa Garland, y prynsbydd Lleidafol. Welcome to you all, and I invite Dean Freeman to make an opening statement. Thank you very much, convener, and my thanks for the opportunity to be here this morning to talk about the health and care staffing Scotland Bill and to answer your questions. The aim of the bill is to provide a statutory basis for the provision of appropriate staffing in health and social care settings. That matters because in our NHS we focus all our work on meeting what is called the triple aim, that healthcare is safe, effective and person-centred. All the evidence tells us that provision of high quality care requires the right people in the right place, with the right skills at the right time, to ensure the best health and care outcomes for those who need our services. Our policy intention with this bill is to enable a rigorous, evidence-based approach to decision making on staffing that ensures that it is safe and effective, takes account of patient and service users' health and care needs, assists the exercise of professional judgment and promotes a safe environment. Providing that means that we need to understand the workload that is generated in any given setting and circumstance, and therefore the skills required and the staff mix that will provide those. My intention is that the bill will put in place a framework to support the systematic identification of the workload that is needed to improve outcomes and deliver high quality care. I know that each and every profession contributes to the delivery of positive outcomes for service users. That is why I have taken the decision to apply this legislation across all staff groups delivering health and social care services. In taking this broader approach, the bill achieves legislative coherence across the health and social care landscape, coherence that is demanded by the integrated health and social care approach that we are taking, which itself rests on the important recognition of value across all staff groups. Providing that assurance for staff and service users is, I believe, the right thing to do. We have the advantage in taking this approach across health and care services because we learned from the existing workload tools and methodology that are developed for nurses and midwives. The development of those tools has been an innovative, evidence-based and importantly professionally led approach. That has led to their use in the Welsh legislation on safe staffing and in the development of workload tools that are used by NHS England. Even starting from that positive position, it is not my intention that the current suite of tools will remain unchanged. It is imperative that they continue to be reviewed and renewed to effectively support multidisciplinary approaches to the delivery of care. The tools are important, but they are only one part of a much broader common staffing methodology and requirements that the bill sets out. The bill puts in place a process that should be applied consistently across health and social care. It ensures that we are using an evidence-based to assess the workload staff are facing and moving away from a reliance on subjective assessments. That is critically important. That is combined with staff using their professional judgment to tailor those assessments of workload to reflect the dynamics of their service and to take their local context into account when deciding how to staff services to deliver at the high quality. That local context will fluctuate and requires a common, consistent workload and staffing methodology and link training so that staff are equipped with the skills to make those assessments. That will have a positive impact on staff, on services and, importantly, on the care provided. Health boards, care service providers and their staff have the shared responsibility to openly and transparently determine how best to ensure that we continue to provide safe and effective services. I would expect to see adjustments made on a real-time basis to take account of changes in workload and more appropriate movement of staff to more effectively acknowledge the acuity and dependence of service users. Substantive posts are used rather than bank and agency staffing. Staff understanding how staffing numbers were decided, staff having the knowledge of how to raise concerns and staff having confidence that their concerns will be dealt with appropriately. The bill does not explicitly define outcomes, nor should it. Our health and care standards and quality measures already define the outcomes that we want to see. In addition to those improvements, the effective application of the legislation will support the wider workforce planning process. If services can clearly identify the workload that is required to meet the needs of the service users, it will be easier for them to workforce plan based on that evidence. When local workforce plans are based on better evidence provided by the consistent application of a common methodology, we will have more robust information to inform national workforce planning and supply. We have listened carefully to those who deliver the services in developing the bill's provisions. We have listened carefully to the previous evidence sessions that you have held. We will continue to engage with stakeholders and to consider their views. As always, I will give full and careful consideration to all the proposals that come forward to strengthen and improve the legislation in the weeks ahead and to the committee's own carefully considered views. Thank you very much, cabinet secretary. That gives us a good opening for our discussion this morning. You talked about both the placing in legislation of existing common staffing methods and enabling better workforce planning methodologies to be developed. Will you regard one or other of those as the principal objective or suggest that they are both of equal weight? I think that they are interlinked. I think that the common methodology is critical, but so are the tools to apply that in order to understand what the workload is and what the skill mix is. All of that, as I said, is important evidence and evidence base for making those assessments and decisions, but the critical importance is, of course, the application of professional judgment to that. I do not think that you can strip out any area of this and still get as good a result as you will do if you put all of them together. One of the things that the committee has heard is the suggestion that desirable developments, although they may not require legislation, some of the existing tools, for example, have all been mandatory for the last five years. Is there any reason why you simply do not enforce that mandatory provision in relation to health boards, rather than seeking to introduce primary legislation? I think that, if I am right, as the committee will understand this from some of the information that you yourself have gathered, is that, although those tools may currently be mandatory, the consistency of their application is not present. What we need to be able to do is ensure consistency of application, not only in our health settings but also in social care. It makes complete sense, given the direction of travel that we are on, which I think—I hope that I am sure that committee members agree with me on that—in terms of integrated health and social care, as well as healthcare and secondary and acute settings, that we apply this methodology to determining workload and, from that, what is the right staffing mix to meet that workload demand across all those settings? To be able to do that requires, I believe, that statutory underpinning that ensures that there is that consistency of approach, because there is a consistency of legislative requirement across the relevant bodies to ensure that that is the way in which they work. The important part of all of that, of course, is its transparency. Some other colleagues here, I am sure, with a more recent experience of health than I have, will nonetheless recall the days when ward charge nurses or sisters used to phone each other to swap staff around. That may or may not have worked in those circumstances, but it was hardly described as transparent, and it was not necessarily a consistent assessment of workload based on an assessment of acuity, patient need and so on. Having it in legislation means that everyone knows what is expected and how to apply it and how to make the decisions based on that. Importantly, for us at a Government level, it gives us greater robust evidence on which to do our workforce planning. Some of the evidence that committee has heard suggests that, if there is an inconsistency in the application of the tools that are already mandatory, it may be because the tools are of different levels of value and usefulness in the eyes of those practitioners whose job it is to evaluate and apply them. Therefore, the question would seem to be one that perhaps might be addressed by management. In other words, if you have made it mandatory, it does not quite work for various reasons. Is that not a matter to resolve in discussion and in light of your management responsibilities, rather than by creating a statutory basis for tools that are clearly not 100 per cent satisfactory in the eyes of those who apply them? People may perceive or may offer the argument that the tools were not satisfactory and that is why I did not use them. I do not have a great deal of patience with that myself, I have to say. It feels to me like a proxy for, can it be bothered? That will not do. Where people have a genuine view that the tools require improvement, there are plenty of opportunities to bring forward those propositions and seek with my colleagues here to make those improvements. Of course, the tools are constantly reviewed and developed as we go along. I do believe that, although some requirement may be mandatory, it is not necessarily followed because other areas get in the way and other pressures may get in the way. I do believe that if we make this a statutory requirement, then everyone, including our health boards and the chairs who are directly accountable to me, will understand that they have an obligation to ensure that the approach is taken consistently across their boards and social care providers, but between boards as well. That gives all of us a much sounder basis for making decisions based on workload, around what our workforce needs are and what the right skill mix is in any given circumstance. Of course, the other advantage of the approach, and this is a particular facet of the tools themselves, is that capacity to be dynamic and to keep measuring in real time. As we know, circumstances in terms of the patient cohort that you are dealing with or the nature of your care home residents that you may be dealing with can change from, in the case of acute hospitals, from one day to the next in social care, perhaps from one week to the next. You need to be able to flex your resource in order to meet that workload demand. Would it be fair to conclude that part, at least of the purpose of the bill, is to enforce a mandatory approach that has not been properly applied thus far? I think that it would be fair to say that part of the purpose of the bill is to ensure that we have a statutory framework that is well understood and therefore consistently applied across our health and social care settings. Good morning, cabinet secretary and the panel. Just to pick a point up there, cabinet secretary, I think that we understand that there is a lack of consistency in the application of the tools across different health boards, but if we are going to ensure that kind of consistency, surely then you have to make sure that there is consistency in dissemination and implementation of training across there. Rather than they can be bothered, it is more likely that the training is not in place to make sure that those tools are delivered. What is going to be different if you are going to prime your legislation in there? What is going to be different in terms of how you are going to support that training and dissemination of that information? I am not sure. I completely accept your premise that where the current mandatory situation is not applied, that will be because training is not available, but I absolutely take your point that when that legislation is passed, should it be passed, there is a requirement to ensure that it is rolled out in a consistent fashion with training and with support to staff and information for staff, so that they know how to use the tools and apply the methodology and what to expect when others are doing that and demands are then placed on them as staff. There is also a requirement to ensure that there is a consistency of monitoring to ensure that that is the work that is being done across health and social care settings. The role of his in that health improvement Scotland in that regard is critical, as is the role of Nez, our education body, to make sure that we have a consistent planned programme of roll-out and training that is continuous, as new staff come on board, that we are able to meet their training needs as well. That would be covered in the guidance that goes with the bill, should it be passed, and in the programme of work that the chief nursing officer and colleagues would take forward. Alex Cole-Hampton. Good morning, Cabinet Secretary, and good morning to your officials and colleagues as well. One of the things that this committee concerns itself with is barriers to integration. I do not mean just the meta definition of integration as it is defined in the act, but a streamlined, integrated health and social care service throughout our country. One of the concerns that has been raised in several evidence sessions is who this bill does not cover. There are, for example, AHPs who are not covered in this bill and to certain aspects of social care, particularly care at home. Are we risking creating yet further silos by not including these other equally valid healthcare professionals and social care professionals in their setting of work? Thank you very much. I think that you raise a really important point. I am very keen that we do not only break down some barriers that currently exist, but we certainly do not, in an unintended way or even an intentional way, create additional barriers. I understand the concerns that you are raising. The view that we have taken—first of all, I should say that in social care settings—I am sure Fiona May will have something that she wants to add to this—in social care settings, when the developed tool that will apply there is worked through, that will, in many cases, include the skill sets that come from AHPs. I do not think that it is entirely accurate to say that they are excluded. As you apply the assessment of workload and look at what are the skill sets that are required to deliver against the detail of that workload, then AHPs, in particular in some cases, have a pretty critical role to play. I believe that they are covered in that way. The point about care at home is a point well made. What we are trying to do—what I am not saying is that, over time, that approach would never apply in that setting. Bearing in mind, in part, Mr Whittle's, or what I believe would be the concern underlying his particular question and some of the other issues that I know have been raised in committee, we want to take a stage-planned approach to that. Moving into the whole health and social care setting of care homes, unlike in the health setting, where the bulk of that is provided by our national health service and care homes, we have a large number of independent providers. We want to properly engage them in the development of a methodology and a set of tools that would be appropriate in their setting and test that out in order to demonstrate the value of that to their work and to their provision of care. We would look to see whether we can move that once people are confident in the approach that is being taken and can see its value. At this point, it is arguably a step too far to include care at home. There are other issues that need to be teased out around self-directed support and other questions that need properly thought through and teased out. We need to ensure that stakeholders have the opportunity to bring forward the issues that they want to raise there and work with us to resolve and find a solution to that. That is, in my opinion, the direction of travel, but it is too early at this point to put that into the primary legislation. Clearly, if that is a direction that we and others wanted to go down in due course, that would come forward as secondary legislation appropriately so that Parliament could give it the right scrutiny at that stage. If I may ask about a slightly different area, the routing of those tools in statute will ensure the uniform application across the health service and, indeed, the social care settings that you describe. To my mind, a tool is something that everyone decides is best practice and expects those at the front line to deploy. We also know from our experience of other inquiries that best practice germinates from the grass roots up sometimes and that wards find better ways of doing things or adapting to the particular situation that they face. How responsive will the toolkit be to grass roots initiative to say that we can do this better and that we do it better and let's apply that across the board as well? I am going to pass at least part of your question if you don't mind to the chief nursing officer and the associate CNO who have a greater understanding of the origins and development of the core tools around nursing than I certainly do. I would make the point before I do that the tools are important, but that is not all that the bill is about. The common staffing methodology is a critical element of that, of which the tools are a part. The capacity and flexibility for the tools to be developed and new ideas to come forward and so on and so forth, I would ask Ms McQueen if I may to respond. I think that we have heard a lot from staff that talk about whether the tools are helpful or not, and some of that is perhaps a lack of understanding. Some of it is a lack of transparency about the do the work and then they think that they are going to get more or different staff and it does not happen. Again, the transparency that will be outlined here will help to support that. I would absolutely expect the professional judgment element of it. If there are areas or ideas that the grassroot staff, the staff for delivering and who know best how to deliver most effectively, the use of professional judgment should help and support that. If there is something that is consistently—no, I am not going to say that, I am going to say this—then that would, through time, be built in with the tool. For instance, if we were looking at acute medicine and at the moment that would just be in a medical ward, it would be a nursing tool. The grassroots and the element from that would be while the occupational therapist, the speech and language therapist, the physiotherapist are fundamental to quality of caring outcomes and safety, so that they would then be involved in that as well. On-going, openness, transparency, professional judgment and moving forward so that we are not saying that we have developed this 18 years ago and that it is going to continue for the next 18 years, so that moving forward and having the constant review. If I could give you an example of that. Yesterday, I was fortunate enough to be in Aberdeen to open the first of our major trauma centres. One of the distinctive features of the work that that entire Scottish Trauma Network has done is a recognition of the importance of occupational and physiotherapy in the rehabilitation of people who have suffered major trauma early, bringing that in early, and psychological therapy. They have built into their model a new post that provides that and a new post that also provides a co-ordination and casework management function in that particular circumstance of high acuity and trauma and so on. Intuitively, what they have done makes sense. It is certainly built on professional judgment, but there is not a common methodology that lies underneath it that has taken them to that place. We are going to have four such centres. I would hope that we would see that learning picked up and used in those other three other centres, but what we do not have is a common basis on which to do it, so views may differ in other centres and someone may decide that that is not something that is needed. With this approach, you have a much more solid basis for saying that that is not just intuitively the right thing to do. We have an evidence base that that is the right thing to do, therefore, where we have a commonality of service major trauma, we would expect to see that range of skills delivered by that different groups of professionals in order to meet the particular patient needs. Suggesting that the whole bill process itself will allow the development of multi-disciplinary tools, patient pathway-centred tools, or a whole process where evidence will be demonstrated so that, as you are describing, when a trauma centre in one place opens and then you have a follow-up, that way we can have a whole evidence-based approach to the whole system so that those tools can be developed, delivered, but in a way that works for care sector as well, which is really important, as well as acute care. I am asking for an affirmation that the whole process is allowing the development of an evidence base that can work across the whole health and social care sector. I think that that is absolutely right. Importantly, it also contributes to the increased robustness of workforce planning, both at a local level, but from local plans that are more robust and more evidence-based, we clearly at a national level have more robust and evidence-based data collated so that we can do national workforce planning with increasing acuity as we move forward. In care homes itself or care in the community, there are no tools for that right now. I am assuming that we will be using the evidence from the nursing tools or acute care tools to help inform so that care homes will not be left behind in the process as we are moving forward. Again, I am going to pass over to Diana in terms of some of the detail, but the important thing about care homes is the work that we ask the care inspectorate to do to enable discussion with those key stakeholders on the development of the tools so that they are appropriate for the care home setting. It is not a rigid lift. The nursing tools that work in the health setting and just apply them over is developed in order to take account of the different circumstances in terms of the care home setting. I will ask Ms Murray if I may to give you a bit more detail on that. That is absolutely right. It is about learning from the approach that we use to develop tools but not simply importing what we have done for nursing in midwifery, say, within an acute adult setting. When tools are developed, they are developed with the people who know how to develop them, who know what the workload is like, who know what the work is like and what the patient pathway is like. They would sit around a reference group and look to the particular models of care for that area. As we heard before, the care in a care home should be about everything around that patient's life and, probably most importantly, about making sure that they are as healthy and as well as they possibly can be and that they are enabled. That would be something that was quite different. In terms of that evidence, that is part of the evidence that we would be looking to. We would also look at care homes who deliver very successful models of care and understand what they have in those models. We would also look at research that there is out there in terms of best provisions of care and best outcomes for people, where the best practice sits. As we work up a tool, we would look at all of the acuity and the dependency around that. In that setting, it is quite different. It is not that acuity in terms of the very sick patient. It is the acuity in terms of how we need to support a person to stay as well and as healthy as possible. As we move through that and gather that evidence, we then work out what that workload looks like and what skills, knowledge and expertise are needed to put round that person to make that as successful as possible. That could be nursing, it could be aHP, it could be in reach from a district nursing team or an advanced nurse practitioner, but, most importantly, it will be developed by the service, for the service, with the service, with the care inspectorate in a lead role, but working with their key partners in terms of a SSC, COSLA. We know that SSC has a huge database in terms of the workforce information and the training, education and skills of that sector, so it would be very much based within that sector. We could find that the key skill that we really need within a care home setting is that of the occupational therapist, but it would be for that sector to do that themselves with support in terms of the methodology that we know works. Thank you very much. You have talked about some of the dynamic day-to-day staffing challenges that people face on ward. The bill clearly is designed to assist with establishment workforce planning, if you like, at a local level. Does it do anything at all for those dynamic decisions that need to be made on a day-to-day basis? Yes, it does, because I think that by having a consistent methodology of which the tools are a part and ensuring that, through training and information and development, that is widely understood and is transparent, that allows what my colleagues described to me earlier is that, by and large, across our healthcare settings or hospital settings, every day there will be different names, but generally speaking, it is called a huddle. That huddle could be at ward level, at specialism level or whatever, where in the old days it was the transfer of reports from the night shift to the day shift about what your patients were, how many you had and what was happening with each of them. It is a version of that done now, but it is also a place where people might be raising right now that they are a short in terms of a particular qualified nurse or a particular specialism. That may well be recognised, but they are asked to accommodate that. What we would have in those circumstances is a situation where people are bringing to that the application of that approach with evidence about why they need a set of particular skills because the acuity levels in their ward have changed and may have changed in a different way from someone else. That allows the proper deployment of staff between those two situations, if you like, in real time. It allows it in a way that is much more transparent, because everybody is working from the same starting point. The approach that we are including in the bill is more transparent and allows for better decision making, I believe, because it is evidence-based, but with that application of professional judgment, and it allows senior staff clinically to flex the resources that they have to meet any particular changing circumstance on a day-to-day basis, as we know that that happens a lot in our acute setting in particular. The evidence that we have heard tends to suggest that the tools are helpful in determining those things from year to year, but not from day to day. I am interested in how the bill changes that provision in a way that makes a difference. You are absolutely right that there is the on an annual basis. As we know, work load has peaks and troughs. As part of the on-going work, we will look at whether we call it escalation or dynamic risk assessment. We will build in quick, easy but open, transparent ways of making sure that where staff have concerns that care will not be delivered on that day-to-day basis, that that can be accommodated, that it can be moved, but we would also expect the application of professional judgment to that. All of that will be reviewed in a systematic way, but we would be expecting that to be taken. Sometimes it is hour by hour, depending on on what situation you have, but it is certainly shift by shift or section of day by section of day, so that we are ensuring that we have a total comprehensive approach every day across our services, rather than once a year. Thank you very much. David Stewart. Thank you for coming out to the cabinet secretary and I welcome your officials. Like many members, I have sat through all the evidence sessions and read all the consultation reports. Clearly, I think that everyone would agree that we want to see an improvement in quality and in staffing. I suppose that the bit that I struggle with, cabinet secretary, and I am very happy to listen to your views on this, is to see the real jump from what we have now to effectively a brave new world in the future, that the bill will make a substantial difference. Can you perhaps outline what the difference will be in quality of care and the adequacy of staffing once the bill is approved? Thank you for that. I should start by saying that I am not promising a brave new world. Even if I am, the bill of its own will not deliver it, but it will be an important part of getting to a situation where we have increasing confidence that our intention in terms of consistent quality of care is based on sound evidence and is consistent across our health service. Now, our health service is primarily a service delivered by people. In those circumstances, as we all know, there will always be occasions where it is not perfect and things do not work quite as planned. There is not a piece of legislation that I could possibly bring forward that would ensure and guarantee that that would never happen. So, there are a couple of clear caveats to put into this, just on a common-sense basis. However, what I think the bill does is that it provides two things. It provides for an approach that has been proven to work and to be effective, to be consistently applied across our health service, and to be translated and modified appropriately into our social care setting, which is, of course, the right thing to do, because we are moving strongly in the direction of health and social care integration. That consistency of application, and more importantly, the evidence that it produces, allows for decision making to be more clearly scrutinised and understood at a local level, be that the ward, the care home setting, or at a board level, or even nationally, to understand why board X is coming and saying that it needs this number of nursing, this number of A HPs. It wants to realign its skill mix in a particular area. It has an evidence base for doing that that is consistent with the evidence base that board Y might come forward with a different set of propositions. We can then better understand, and as more transparent, having involved appropriately all the staff who should be involved, and it is not simply a management decision. The whole approach is led by an increased understanding of workload, the workload that is produced as a consequence of patient or service user need. That workload tells us what kind of staffing mix we ought to have. That is transparent and open and therefore challengeable. Decisions that I might make, or decisions that a chargerless and a ward might make, or a care home manager might make, are challengeable, scrutinisable and evidence-based. That allows us to then say, as we go forward, that those are our workforce needs now, but those are our workforce needs in the next years ahead. That is produced directly from an understanding of what service user and patient need produces by way of workload. That is a substantial difference in terms of what the bill provides and a significantly important grounding for some of the work that we need to do both nationally and, of course, at local level. You mentioned transparency. I can raise a further point about transparency and empowerment of staff and, indeed, patients. Let me give you a practical example. If I raise new craigs in Vanessa, which I know fairly well, I know some staff that work there, and in my previous life I worked in my mental health officer training in the old new craigs. I have some experience of that organisation. I know from personal experience of staff that work there that there is an absolute chronic staffing problem, which I have raised with the health board, and I have visited the key managers to discuss it. If the staff wish to complain about this issue, we have current procedures, what could they do in terms of healthcare improvement in Scotland? You will know from last week's evidence that I asked some of the key staff there, about what the new regime would look like. What would the mechanisms be for staff and for patients, indeed, if they were very unhappy about inadequate staffing in that establishment, just to give a practical example? We would want to work with stakeholders to determine how we could do this most effectively, because it is something that staff will tell us that they are not quite sure what to do, or they put something into the instant reporting system, and nothing happens or something happens in three months' time. It is something that we would want to work with stakeholders, the colleges, along with healthcare improvement Scotland and staff, and you rightly say that patients and service users, we would want to work with people so that we could get something that is meaningful, practical and makes a difference. I will add to that that one of the things that the RCN has said about the current draft legislation is that it welcomes the proposition in it around escalation. It obviously has a view about further strengthening of that and what that might look like. We are certainly open to further discussion about how those situations and the situation that you have described in that circumstance, how staff can escalate that, where they believe that the concerns that they are raising around staffing levels to meet a workload demand are not being properly listened to, and what they might do as a consequence of that. It is an important point as we raised earlier about how we extend training and information and how we ensure that what is in that legislation is implemented in a consistent way. It is one that we will give some further thought to. I should have added that I am sure that the cabinet secretary, I am certain that I have invited the cabinet secretary to a new case in the future. I am sure that she has a busy schedule, along with Fiona McQueen and her colleagues. My final question is looking at what we have currently and looking into the future. What recourse, other than the board's own complaint procedures, could an individual pursue if there was a failure in service? The cabinet secretary is aware of the Royal College of Physicians' view that they do not feel that there is a full transparency if the boards do not fulfil the individual aspects of the bill. That is two aspects. What is new about that? Can you give me a little bit more about what you are asking? Are you talking about an individual patient in terms of what they might do or a staff member in what they might do? Yes, both. I was lumping both together. It is very important that we empower staff and indeed patients. Clearly, if there is a failure in a quality of service or a failure in staffing, that will impact on the staffing and indeed on the quality of the experience that patient will get. The bill inserts into the 1978 act. It becomes part of that, if you like. It is linked to that act. That act gives a number of powers to ministers that we can exercise, which includes power of direction, if we believe that a board is not meeting its statutory responsibilities or failing to meet those adequately in some way. That is at the upper end of the scale, if you like. In getting to that end, there are a number of steps. Patients have the opportunity for individual complaints, where they believe that the board has not fully addressed those complaints. We have the public service ombudsman also there. We have the importance of care opinion, although it carries no direct sanctions. It is certainly widely read and used by our boards. I review it regularly myself to see what people are actually saying about the care that they have received. In terms of staff, there is, of course, the formal grievance procedure. In addition, as I said, I am more than happy to consider anything that might come forward from the ACN or others around the escalation process. In addition, we have the regular reviews that go on between my officials and boards, including the work on the partnership forum, staff governance and clinical review committees, and the annual review that I and my colleague ministers conduct of board performance. If boards, as we have had in other examples, where there is what we describe as a postcode lottery, where there is provision of, for example, treatment in one area and not in another, you would have more central control to ensure that the board does what is laid down in the act. I currently pick up and pursue those situations where they are raised with me, and I do not often understand the reasons that I raise by myself or my colleagues is not receiving treatment. Where there are clinical decisions, of course, that is something that no politician should start guddling around in. Lord would help us, if we ever did. However, there are other circumstances in which what I would expect a board to be doing is not necessarily being applied consistently, either in that board area or between boards, and we pursue those individual circumstances. On the same topic, in social care, if a provider is unable to comply with their new statutory requirements, what are the consequences there? Of course, the care inspectorate has a number of powers that they can exercise and do, including looking to secure improvement and giving and putting in place improvement notices right through to a situation in which they will go and seek a court-approved sanction to close a care home down if they believe that the residents there are at risk. We know that they do exercise those powers, and they would be exercising their inspections on the basis of what is in the legislation through the Parliament to prove it. Good morning, cabinet secretary. Good morning to your officials. I will probably come back to what David Stewart had asked at the beginning. Possibly in a nutshell, people have been asking me. I hope that you forgive me for having listened to all the evidence. It is becoming clearer now to me about what is happening with not just the tools but how it is going to drift down into the care sector, and that is something that has been raised with me. I just want to know that you mentioned the fact that secondary legislation and stuff will be translated and modified. Is there a timescale in which you think that once the tools are in place, in the nursing and hospital setting level, is there a timescale when it will filter down to the healthcare situation? We have heard from evidence last week from the HPs, the trade unions and the care inspectorate that they are working together. They look forward to this coming in. They are working together at the moment, but nobody knows when, if there is a certain timescale, this will go down to, as somebody else said, the grass-roots level, which I am very interested in, such as integration and health boards. It affects people in care homes. Do you envision a certain timescale, or can you give us a timescale? Either or both of my colleagues may want to add something to what I am about to say. However, the fact that those bodies, as you have described, are working together and are looking forward to the draft bill becoming legislation gives us a bit of a significant indicator about how quickly we should be able to manage that. We are taking the proven evidence-based methodology used in nursing and midwifery and looking with the direct involvement of the care inspectorate, enabling that to happen, to take those tools and where they require modification for the care home setting, put that modification in place and do it in a way that involves those organisations that are active in the care home setting. As soon as that is achieved, they will be applied. In one sense, they are the masters of that timescale because they will be the ones directly involved in ensuring that what they are expected to do, that they have been directly involved in developing and designing that base, but they are starting from a set of tools and a methodology that has already been proven to work in a particular setting, and they will then look to how they apply it into the care home setting. That is the care home setting. That is not care at home. As I explained to Mr Cole-Hamilton, that is the direction that we would look to go in, but the bill does not cover that, rightly so, because we are not ready yet to move there. Should we get to that point where we are ready to move there, then that would appropriately come back as secondary legislation for Parliament to give it due scrutiny. I do not know if either of you want to add. We have increased the infrastructure around that as part of the development of the bill, and we have a process for the review and maintenance of the current tools that we have, and also for taking forward evidence where we feel that the development of new tools needs to go next. There is a national group working on that to see where we feel that we should be going to next. That group will bring forward proposals based on the intelligence of the sectors that they are working with. In terms of care homes right away, and the other ones with due regard to providers' needs, etc. I just add to that. It partly is additional information in terms of your question, Ms White, but Mr Whittles, if we look at the financial memorandum, we will see in that the costs set out that cover the development of the tool, staff training, support for boards and others in order to do that work. We are planning all that into what we have before us. Thank you very much, because that was one of the issues that I raised about the financial memorandum previously, and I am pleased to see that it is there. I am assuming that it is a moving feast, and there will be checks and balances as it moves along, so that will be transparent for everyone to see. One of the issues that was raised by the trade unions was the very local authorities, and it is not taking into account care at home, so that is something that I am presuming that you will be looking at again. I will put something into the mix, or maybe take something out of the mix. Obviously, there is Brexit coming up. We have an ageing workforce that was given in evidence to us, particularly in care homes where they have perhaps an older set of nursing, which are multifaceted. How is that going to affect this bill? Have you put that into consideration for all the tools, particularly the Brexit situation in care homes and having staff coming here? Ideally, I wish that that was something that you could have taken out of the mix. That would have been a significant help, I think, to all of us. Unfortunately, you cannot and neither can I, but equally putting it into the mix is a bit difficult, too, because we do not know the circumstances that we will be in. It will undoubtedly be the case, though, that if we end up in a position where we have fewer EU nationals working in our health or care settings in Scotland and even worse, those who are currently here no longer feel that it is where they want to remain and return to their home country, what that produces for us is a significant difficulty in workforce numbers, which will be exposed in part by the application of a methodology and a tool that looks to provide evidence on workload demand. It provides evidence on workload demand, and professional judgment is then used and applied to that. That tells you what kind of skill mix you should have and where you should be getting that from. If you are then struggling in a sense, because some of the individuals who may have provided that to us right now and in the past are no longer here, then there is self-evidently a difficulty. In fact, I firmly believe that it is worth saying that no responsible Government would ever say that it is possible to completely mitigate all of those risks. Part of what we are doing is looking at how we, as is described, grew our own. For example, I was in Wishaw General last week, where they have developed, as Golden Jubilee has, their own theatre academy in order to upskill their nursing staff. As the newly qualified trainees come out ready from that significantly six-year and a row increase in student trainee numbers that we are pursuing, as those new trainees come out, existing staff can be upskilled to take on additional roles. That growing of our own, the work that is going on in terms of our further and higher education sector is looking at articulation between college-based courses into higher education, working with young people and preparing to leaving school so that they have some foundation level work for health and social care. All of that is about increasing the numbers of individuals who will look to health and social care as an opportunity. Last night, as it happens, I was at Princes Trust awards, where the Get Into Healthcare programme not only produced a couple of award winners, but we were able to also talk about the new partnership with Princes Trust that will give health and social care opportunities to an additional 400 young people. All of that, there are a range of actions across not just my portfolio but other portfolios in government looking to increase the opportunities and the throughput from young people and others, women returners as well into health and social care. All of that is the right thing to do. Will that mitigate the difficulties that whatever form Brexit takes it will give us? No, it won't mitigate that completely. There will be difficult decisions to make and issues to resolve once we know what we are dealing with. There is nothing in the bill or in the financial memorandum to the bill that in any way helps employers faced with severe staff shortages, either in health or in care. The financial memorandum talks about the cost of implementing the bill. It does not, appropriately, talk about the cost of employing staff. So, no, there isn't in that circumstance. If I lead Brexit to one side, the older workers, Ms White, rightly raised, and I think what that will do is, again, if we listen to staff, they talk about workload and it being difficult. We know that there is a real evidence base that meaningful fulfilling work is good for one's health. Again, putting aside differences about the pension age, the reality is that meaningful work is good for people's health. What that will do is make an appropriate assessment of workload so that, no matter what age you are, you should be able to come in and do your job and not be exhausted but be fulfilled and take pleasure in it. I think that we will also be able to look at how we support the older worker to continue to work. Cabinet Secretary, I think that it has been very eloquent about a lot of the work that we are doing to widen access and to bring other people in. I think that that will help. I would expect it to make a difference to our older workforce to be able to keep them in employment, because we are absolutely having safe and appropriate staffing that has come in to stick with the workload that people are facing. Brian Whittle I think that it is probably appropriate to refer members to my register of interests here. I am still a director of a company developing communication and collaboration platform and tools, including for healthcare profession. The SSTS sits on or piggybacks on the back of the payroll platform, which is not unusual, but that means that we are basically bolting on software tools on to a platform that was not initially designed for that purpose. The evidence that we have heard so far has the suitability of that platform going forward. To start off, I ask what the sequence of events that led the bill to legislate for the use of the tools that, in essence, as we have heard, are becoming outdated on potentially an unsuitable platform before procuring a new bespoke platform and reviewing and developing the robust workable tools for that specific platform? I will let Ms Murray explain or take you through some of the detail in responding to your question. However, as you know, Mr Whittle, one of the key bits of advice that Audit Scotland always gives in terms of IT and IT platforms is that, if at all possible, do not build from scratch, do not build brand new. Look at what you have and see how you can adapt that. What you have that works, see how you can adapt it. Look at what is on the shelf and see, again, proven workable platforms and see if that too can be adapted to meet your existing needs. If none of that works, or if you are left with a gap, then you build from new. That is the approach that we take in Government. It is absolutely the approach that I took in social security and it is the approach that I would take in health. In terms of the specific detail here, I would ask Ms Murray to deal with that. I think that you are aware that the SSTX platform is our payment platform for NHS Scotland. The tools were put on to that platform because it was the most appropriate place to put them at the time. When you know how to use the IT around them and when you know how to put the information into the SSTX platform, it is fairly simple. I hope that the team will be able to show you that this morning. We are going out to procure an e-rosting system, as the committee is aware, and we will complete that by the end of this year. When we get that system in place, which will give us all of the real-time information in terms of our rosters that fit into that approach, we will then take an on-balance view of where is the best place to situate the tools, whether that continues to be on that platform or any new platform that is procured to undertake our payroll system, or whether it would be on any new platform that links with our electronic rostering. We need to understand the capabilities of that before we move to do anything like that. The tools are capable of being revised and renewed as we move along. The tools are capable of taking into consideration the context of the service in which they are provided. The platform that they are on is a repository of that information, and it produces reports for us. When we better understand that as well, we will know where the best place to situate them is. The link has to be there between the electronic rostering system and the tools platform. That is something that, through that procurement exercise, we will be absolutely clear about so that the systems can talk and feed to each other. That work has not concluded yet, so that is probably as much as I can say about that. However, being sure about what we need on any IT system is the first premise, then it is actually the procurement of it. Understanding what we need is our first premise. Cabinet Secretary, you are right. Of course, you do not procure build-from-scratch, if you can possibly avoid it. In this sector, the undeniable would be tools or platform that you can take off the shelf at the very least can be adapted. The question, in developing tools that will sit on the current platform, surely the best process would be to understand the platform in which they sit prior to developing tools, because you will develop a different tool for a different platform without question. We will have to do both. The tools, the ones that we have that sit on that platform, sit there in the way that we intended them to sit. However, if we develop something different, you are quite right that it may sit within an IGB setting. We have to consider that. We absolutely need to be considered as part of that as well. You are in a procurement lip at the moment looking at the platform in which the new tools will sit. We are looking at the moment at the e-rosting platform. We will then take a decision as to whether we maintain on this site or we transfer over to that. As part of that procurement exercise, that is part of the questioning that will be asked in terms of the ability to feed our workload tools platform. In the financial memorandum, it refers to the work of the nursing and midwifery workforce and workload planning programme in developing the new tools. Will they be carrying out the work for other NHS staff groups and settings, as is indicated in the financial memorandum? As we said before about the care home setting, we will use the learning from that, but that work cannot take place in isolation of the staff that know how to undertake that work. If we were thinking about a multi-professional tool, the group that we would bring together around that would be a clinical reference group that includes all of the people who would be working on the development of that tool. It has to include more than just nursing, but the learning from it is the important part. That is learning that has been taken forward both in the Welsh legislation and in the tools that have been developed in some of our English settings and in some of the multi-professional tools. We know that that learning is robust, but we need to bring the evidence from the other services and from the other professions into that process and not through the baby out with the bathwater but to be able to change and adapt according to the requirements that we find. With reference to multidisciplinary teams and multidisciplinary tools, we have had concerns from bodies such as allied healthcare professionals suggesting that they feel that they might create a two-tier system and that they might be left behind. When do you envisage bringing them into the development of the tools? As I said earlier, when you apply the developed tools in terms of the care setting, it is most likely—and it may even be in the hospital setting—that as you look at the workload and you look at what is the right skill mix, allied health professionals are the very people who have the skills that you are looking for to meet that particular need. In developing the work that we have described earlier that the care inspectorate will enable in looking at how the current tools are modified and reviewed and applied to a care home setting, we would expect to see a degree of expertise from allied health professionals being involved in that work to develop the tools that would be appropriate for a care home setting. Can I say that I suppose that listening to all the evidence sessions that we have had and being new to this committee, I have kind of got in my mind now that this really is a bit like the police who would have intelligence-led policing, which the cabinet secretary will know from one of our previous roles. It is the idea of being evidence-based but also allied to professional judgment. We did have evidence from Unison, in particular, who were concerned about staffing, as she would expect them to be. I made the point then that I would have thought that this would help in that regard, because if you continue to apply the tools and the common methodology, it would show up where there was a requirement for increased staffing. I do not think that they saw it that way, but that is the way that I saw it. Ms McQueen said at the start that sometimes existing tools have been applied and that that led to an expectation that it would result in increased staffing and that people have been disappointed. Are you confident that that was because they ever ensured that it was not required? I suppose that that is the part of the question. Do you think that this is a tool that will help both providers and commissioners of health and care services to recognise when there is a need for increased staffing? The short answer to that is yes, and there are a couple of reasons for that. First of all, I should let me just mention in passing the point that I made earlier about escalation and looking at how that works. Secondly, there is the point about when you have a consistent methodology that produces evidence of workload that you then apply professional judgment to, and you have that on a statutory basis with both Health Improvement Scotland and the Care Inspectorate, required to take into account looking at whether that has been applied properly and then acted on, then you diminish the opportunities for people to be disappointed because they believe that they have produced evidence that they need set of skills why and it did not happen. You increase the likelihood that those who made the decision not to respond positively to that evidence have that decision very clearly scrutinised as to why they did not do that then when the evidence was there and the professional judgment was applied. Knowing that that is the basis on which you will be inspected, that is the basis on which improvement notices will be put on your service, that helps people to understand the importance of consistently applying not only the methodology and the tools but acting on the results that that gives you. I expect it to be a significantly improved situation from the one that we have now. That does not mean that the passing of this legislation guarantees that staff will not be disappointed. They may be disappointed because they may nonetheless feel that the solution that was provided to them was not the one that they wanted. As long as that solution can be defended in terms of the proper use of the evidence and the clinical judgment and the circumstances in which the local context is described, that decision is fair. What is most important about it is that it is clearly set out and understood and that is my point about transparency. Part of the disappointment—if I cast my mind back in quite a long time, I can recall this—is feeling that decisions were made and nobody ever really explained to you why they were made. You did not know why did ward A get that extra pair of hands and my ward did not. Was that just because the manager did not like me or like that part? All sorts of different possibilities run through your mind when you do not know transparently and clearly what is the basis on which that decision was made. One of the things that the legislation does, of course, is address that. David Torrance Good morning, everybody. You touched on it earlier, cabinet secretary, about flexibility, but does the bill allow for sufficient flexibility for working change and technology change? How quick can it react and implement it? Changes to working process and technology and how it changes staff. I think that in terms of changing working practices, absolutely, and I think that going forward, when things change and the changes within healthcare delivery have been quite dramatic and remarkable over the past, say, 10 years, so there would be no point in saying, well, 10 years ago this is the staffing you need, so that is what is going to continue. Sometimes that increased technology means that more complex care can be carried out and people are iller and frailer and need more staff, and sometimes that technology means that no staff are needed because there is a technological solution. That is why the consistent application of the tools, the routine and regular application, the professional judgment involving service users, patients views, staff views and taking it forward means that we will absolutely be able to embrace and we know that the future will be different in terms of taking this forward, so we would expect to see that. What mechanism is in place for sharing the good working practices across NHS because sometimes management is slow to adapt or take change on board? That is a fair point. One of the important parts of the bill is because you put this approach on that statutory basis and it is part of the work that Health Improvement Scotland does when they are conducting their inspections and the care inspectorate, when they are conducting their inspections, is that you rely less on the spread of good practice because you now have a statutory requirement. I am not suggesting that we have statutory requirements in every area where we might want to spread good practice, but I think that it takes us away from that circumstance where we are relying on good practice spreading and we are actually putting a statutory basis here for this. That is not to suggest that people do not pick up good practice because they do not want to, but other things get in the way and other priorities in terms of the work that you are doing day to day and things that will take priority, for example, are your statutory duties. Putting that on to that legislative framework gives it greater robustness and force in terms of what needs to happen. Can I seek some clarification around some of those points around that? First of all, is it still the intention that boards would be required to report on the application of the tools rather than necessarily the outcomes of the common staffing methods in terms of future staffing numbers and so on? Is it specifically on the application, whether or not the tools have been properly applied, that boards would be reporting? No, it is not. We expect boards to report on not only the application of the tools, but the outcomes, and we would expect Health Improvement Scotland and their inspections to be looking at that. And would Health Improvement Scotland, in order to do that, have powers and the ultimate sanctions parallel to those that we have heard of that are available to the care inspectorate, where they are able to take fairly significant measures where commitments are not fulfilled? In their inspection role, Health Improvement Scotland has a number of powers already in terms of how they inspect under that role, and they would continue to have those, obviously, in this area. They also have an important improvement function, so they have a role and a responsibility where standards are not being met and duties not being complied with to offer improvement support to allow people to improve and meet those standards or fulfil those duties. Then, of course, there are other steps, should that then subsequently not happen. What would you expect a health board to do if it applied the statutory obligations contained in the bill and found that it was not able to meet all of those requirements that were put upon them as a consequence? Should a board be using the tools and, as a consequence of that, the application of professional judgment not be able to fulfil the rules? I would expect the board to be doing two things. I would expect the board to be very speedily informing me or informing the Government of that and discussing with us what alternative solutions there might be in those circumstances and working with us to see if we can resolve it in the medium to longer term. I would expect the Government or the health department in terms of workforce planning to be taking note of that and making a view as to whether that was a particular set of local circumstances or something that we were seeing evidenced as a trend in a particular area of skills or expertise. Thank you very much, Emma Harper. Just a couple of additional questions about care homes and care inspectorate. In the policy memorandum paragraph 84 through 90 talks about care inspectorate and on the care side it says that the bill sets out a mechanism to develop tools and methodology for care homes for adults in the first instance and the bill, the legislation does not seek to prescribe an approach to workload or workforce planning on the face of the bill in care service settings but rather to enable the development of suitable approaches for different settings. I know concerns have been raised about staffing in care homes and how it is really difficult to recruit for care homes. It was one of the comments that was said that it is already at the bottom line in terms of resource for providing the service. I am interested in to know what efforts are under way to address the concerns of the care sector and the risks of any consequences because of the challenges in recruitment at the moment. I understand the concerns that the care sector raises. I think that it would be inaccurate to say that those are concerns that are evidence-based across the entirety of our country. We have other parts where care homes are successfully recruiting and recruiting at a significant level to meet their needs. There are a number of initiatives already under way to try to ensure that we have the availability of staff for care homes. Some of that is about care homes working in clusters where, for example, they may have need for allied health professionals in terms of occupational therapy or physical therapy, but they can share that staff resource in other parts, at least in one local authority, where they are as a local authority, having reorganised their services but having a policy position of no compulsory redundancies, offering retraining opportunities while still employed by the local authority to staff who want to retrain in order to take up opportunities in both care homes and childcare. The other initiatives that I spoke about in terms of the articulation between school, college and higher education work are particularly focused on young people and on adult returners. In local settings, there are often opportunities that are possible for women to return to work and to do that in the care home setting. Our application of the living wage to care home workers is an important element of making care work, care home work, attractive to people. I do not know whether Fiona or Diana want to add to that. We are working with the Scottish Care, the Royal College of Nursing and other stakeholders, so my team is leading that work with other Government colleagues so that we can enhance the nursing contribution into care homes and almost define it as to how it would be. I recognise that in some areas it can be a challenge but some of the practical issues about supporting people who are care workers within care homes to do their nurse training, the way that we have done in the NHS for some time, as well as other wider work of looking at how we support care home staffing in general. I know that work is going ahead jointly with COSLA under part 2 of the national workforce plan simply to ask if you are satisfied that there is no contradiction between the requirements of the bill and the work that is under way already and that there will be no disruption to that joint working that is being done around the national workforce plan. I am satisfied that there will be no disruption to that joint work. The joint work is really important but I am also confident that the bill should become legislation that it will significantly contribute to robust workforce planning across health and social care. Thank you very much and I thank you Cabinet Secretary for your attendance this morning with your officials. I will now suspend for two minutes in order to allow the panel to leave. We are still in public session and we are looking now at the European Union withdrawal act measures. This is a further proposal from the Scottish Government to consent to UK Government legislation using the powers under the withdrawal act in relation to three separate instruments, the human tissue quality and safety for human application amendment EU exit regulations, the quality and safety of organs intended for transplantation amendment EU exit regulations and the blood safety and quality amendment EU exit regulations. Members will have seen the note from the clerks that identifies that each of those regulations is identified by the Scottish Government as falling under category B. Most of the content is technical and minor but they do involve matters where we may wish to take evidence on the notification from the Scottish Government and potentially from external stakeholders. Colleagues will recognise that those regulations relate to matters that we will consider in great detail after the October recess, so there is a relevance there as well. The letter from Jo Fitzpatrick states that he requires her to apply within 28 days but that does not include the 14 days of the recess, so we have until 10 November. Although that paper only reached us on Friday, I suggest that we have it on the agenda today so that we can make a decision today as to whether we want to obtain some evidence before approving or otherwise those regulations. I have looked at the suggestions about writing and having people in to answer questions. I am really quite concerned in regard to the contents here. When you look at human tissue, blood and transplant, what has happened—I am not going to give the whole thing—I know that that is for questioning, but I think that it is imperative that we have an evidence session. You are talking here on various things that have far reached in consequence, as far as I am concerned, so I think that we do need an evidence session on it. It is certainly relevant. We do not need to make that judgment today, though. I think that all we need to decide today is whether we agree to write to the most interested parties, if you like. When we get their replies in the first meeting, after the recovery session, we can decide whether that is enough information or we need to take further evidence. Thank you. I just wanted to know what flex there was in our work plan, should we decide to take such evidence? There is a little—clearly after the recovery session, we are running into the human tissue authorisation bill, which is pertinent in the sense that those matters relate clearly to that. Given that convergence, it is possible to imagine a half-hour session if we feel on the basis of the evidence. I suspect that we should obtain that written evidence first before coming to any of you as to whether we need it. If members are agreeable, we will issue correspondence to the organisations that mentioned in the clerks paper and return to this at our meeting immediately after the October recess to consider the responses that we have had. Thank you very much and, as previously agreed, we will now move into private session.