 Felly'n bob yn iawn i gynnwys I yn dweud i'r ffaisiw oldeithasol i G1 yn ynmóon 1505 i Llyfrgell GŚ i G1 yn y Cynghreifeth Cynghreifeth Cymru fynd i'w ddod i G1 yn dweud i G1 i'r fferwyr i G1 yn dweud i G1 yn y cymdeithasol i G1 i'r fferwyr i G1 i gyd. Rhefnidol eitem ni'n ddwy iawn i G1 i gymuno i G1 i eitem ni'n ddwy iawn i G1 i'r fferwyr i G1 y wirth. health care. Ensuring that we all have continuing and improved access to the right care at the right time has been the guiding principle of our approach to health and social care services, but this is a significant and complex task. In common with healthcare systems elsewhere in the world, we are living longer but not yet healthier lives. That brings the challenge of more complex health conditions to more of our citizens. In meeting the increasing demand on our services, it is essential that we act to make sure that our whole system of health and care has the capacity, focus and workforce to address the needs of our changing society. I have set out my expectations for improved mental health services, improved access through the waiting times improvement plan and continuing pace in the reform of our health and social care services underpinned by improvements in primary care, but those can only be secured through the hard work and dedication of our health and care staff. There is a compelling argument that having sufficient staff working in a psychologically safe environment is integral to good patient outcomes. That is why we need to put measures in place to ensure that, at all times, we have evidence-based safe levels of staff. The health and care staffing bill is grounded in and builds on the excellent approach to workload planning led by our nurses and midwives. The development of the staffing methodology and speciality-specific tools has been an innovative, evidence-based and, importantly, a professionally led approach, an approach that has led to their use in the Welsh legislation on safe staffing and in the development of workload tools used by NHS England. Recognising its value, we made a manifesto commitment to secure this approach in legislation. The bill now goes further than that commitment. It puts in place a framework to systematically identify the workload that is needed to approve outcomes and deliver high-quality care. In developing the bill, we carried out two consultations and held 10 public events. My officials, my predecessor and I have worked with representatives of nurses, doctors, allied health professionals, health boards, local authorities, care service providers, professional bodies, trade unions and others to take the principles of an approach that works in one part of our health and care system and enable the spread of that across the whole system. Throughout, we have worked hard to listen to ideas and views and look at how we can make this work. I recognise that there can be competing interests, that our integration agenda is ambitious and that the approach that the bill encapsulates will require a significant cultural shift in our health and care organisations. We saw that reflected in the evidence taken by the health and support committee, but I believe that, throughout, it has also been clear that the bill is an opportunity. It is an opportunity to enable a rigorous evidence-based approach to decision-making on staffing that takes account of patients and service users' health and care needs. It will identify the workload that is required to deliver those needs, assist the exercise of professional judgment and promote a safe environment. It is an opportunity to ensure that the professional judgment of our staff delivering health and social care is heard. It is an opportunity to create transparency around staffing decisions, transparency that aids healthcare improvement Scotland and the care inspectorate to support improvement across our health and care services and giving staff and patients the confidence that, at all times, decisions are made around staffing for safe, effective and person-centred care. Healthcare Improvement Scotland and the Care Inspectorate will play a crucial role in the implementation of the approach. Both will be responsible for facilitating the development of staffing tools and methodologies in collaboration with the services that will use them. In doing so, it will identify, develop and implement continuous quality improvement, rather than focus solely on compliance against minimum standards. Giving his a specific function on the face of the bill has been raised, and I will bring forward an amendment at stage 2 to make the role of his absolutely clear. The bill puts in place a methodology and procedures to ensure that health boards and care service providers ensure that they have appropriate staffing. What it is not about is nurses alone, nor is it about setting a minimum number of staff to deliver any particular service. It is founded on the innovative approach that our nurses and midwives have developed, which starts with a robust evidence-based assessment of the care that people using our services need and want. Only once we understand that can we be sure that we understand the workload, the skills necessary to meet that workload and to know what staff need to have in place to deliver that care to a high quality. The voice of the professional must be heard as part of this process. The increased transparency that the bill requires will make obvious the workload that exists and the corresponding skills that are required to deliver high-quality care. That assures health boards, Healthcare Improvement Scotland, the Care Inspectorate, Health and Care staff, professional bodies, trade unions, the chamber and the cabinet secretary, and, importantly, the public, that we have the right staff with the right skills in place. I believe that that is exactly the right thing to do, yes, of course. I am grateful to the cabinet secretary. I agree that it is important that staff are listened to. Recent figures revealed that there have been 1 million stress-related absences, that is 1 million days in the last three years, within the NHS that is not covering social care. What is the Scottish Government doing now, outwith the bill, to address that, to make sure that the concerns that staff have now about safety and treasure in their workplace is being addressed in real time? I am grateful to Ms Lennon to raise this matter, I know that she has raised it before. Like her, I take stress-related, indeed, any absence very seriously in our health service. There are a number of measures that our boards are putting in place in terms of mental health support for staff. Of course, we need to recognise that all stress arises from workplace issues. Sometimes it can arise from personal domestic issues, but nonetheless impact on an individual's performance and enjoyment of their work. The measures that we are beginning to put in place across our health boards do not distinguish, but they simply say how we can help staff undertake to do that. I am happy to give Ms Lennon more detail on that matter and to discuss further with her if she wishes how we might improve on that. It is clear from my conversations with representatives of staff groups that the bill could be improved by placing a more explicit duty on health boards to ensure that there are clear mechanisms for day-to-day assessment of staff needs and clear routes for the professional voice to be heard in those assessments, so I am pleased to confirm that I will bring forward an amendment at stage 2 to include that. The effective application of that legislation will also support the wider workforce planning processes. By providing that evidence-based information on workload at a local and service level, planning the workforce needs locally, regionally and nationally will be enhanced. I know that each and every profession contributes to the delivery of positive outcomes for service users, and that is why that legislation applies across all staff groups that deliver health and social care services. The general duty is to ensure that appropriate staffing and overarching principles that span all staff groups, not just nursing and midwifery. That will support multidisciplinary planning and service delivery and will also mitigate the risk of unintentionally diverting resources towards nursing and midwifery at the expense of any other staff group. Alex Cole-Hamilton is very grateful to the cabinet secretary for giving way. Although the bill is very worthy, it is nothing without adequate workforce planning underpinning it. We cannot legislate to make staffing safer and expect it just to happen. Can the cabinet secretary confirm that the bill moves towards the methodologies and toolkits that are described in the bill and that staff will not be moved out of non-acute services to ensure that we are staffed safely in acute services? Yes, I can confirm that. The bill, as a legislative framework around a methodology, is, as I am in the middle of saying, applying to all staff groups across health and social care to do anything other would indeed be to risk those unintended consequences of moving a resource from one area at the expense of another. Absolutely, workforce planning is critical, but good workforce planning is based on sound evidence. That is, as I will come on to say later, one of the important components of producing that sound evidence at a local and at a service level, feeding into health boards workforce planning, but also IJBs and through them international workforce planning. In taking that broader approach, the bill achieves legislative coherence across the health and social care landscape, coherence that is demanded by integrated health and social care and which rests on the important recognition of value across all staff groups. It is, as I have just said, another lever to join up services, support innovation and redesign, and deliver sustainable high-quality care. In taking that broader approach, the legislation will not be restrictive or prescriptive, but will be appropriate and enabling for the social care sector and in particular support the direction of travel set out in the co-produced part 2 of the national health and social care workforce plan. Any new tools and methodologies would be developed specifically for and by the professionals who will use them. The current suite of tools will not remain unchanged, but will continue to be reviewed and renewed to effectively support multidisciplinary approaches to the delivery of care. We are taking a multidisciplinary approach where that is appropriate and I will again look to amend the bill at stage 2 to make that clear. The Government is committed to ensuring that Scotland has the appropriate staffing for the delivery of safe, high-quality care. The bill will contribute to that aim by placing a duty on health boards and care services to ensure that appropriate numbers of suitably trained staff are in a place to provide safe and high-quality care. It requires health boards to apply evidence-based and professional-led approaches to nursing and midwifery workforce planning. It promotes a continuing culture of transparency and engagement with staff and facilitates the future development of that approach across health and care settings, with tools being developed through partnership and taking account of the size and complexity of the services. I believe that we can all agree that the framework offered by the bill to put in place the right numbers of staff in the right place at the right time and with the right skills is the right thing to do. I believe, Presiding Officer, that so far I have addressed many of the issues raised by the Health and Sport Committee in their stage 1 report. I welcome their support for the general principles of the bill, and I want to take this opportunity to thank the committee for their full consideration of the complexity of the approach, especially in the integrated landscape. In particular, for their view, which I most assuredly share, that the professional voice must be heard at all levels. However, of course, I know and acknowledge that we are not all in agreement on every part of this bill. I have welcomed the challenges and the constructive discussion that we have had so far. I will commit to continuing to work with those who deliver health and social care and with members both on the committee and in this Parliament to do all that we can to make sure that we have the right statutory basis for the provision of appropriate staffing in health and care service settings. I think that this is an ambitious piece of legislation that will provide a critical contribution to driving the necessary and important cultural and organisational change that we need to meet the challenges and the expectations on health and social care in Scotland, all with the Parliament objective of providing improved, safe, effective and person-centred service and outcomes for people in Scotland. I move that the Parliament agrees to the general principles of the health and care staffing Scotland bill. I call on Lewis MacDonald as the convener to speak on behalf of the Health and Sport Committee. I am pleased to report as convener of the Health and Sport Committee on stage 1 of the health and care staffing bill. Our report was agreed unanimously across all parties and makes a number of what we hope are constructive suggestions to enhance the bill. I would like to start by thanking all who assisted the committee with our scrutiny, those who responded to our call for views and our survey, those who gave oral evidence and the many staff who participated in our plenary session at the NHS anniversary event in Glasgow in the summer. Many front-line health and care staff gave up time and very busy schedules to engage with the committee and I want to record our thanks not only for their invaluable input but, of course, also for the very important work that they do. The cabinet secretary responded in writing to our report yesterday. Her offer to keep the dialogue going is very welcome and so, indeed, are the commitments that she has made this afternoon on areas where the Government intends to bring forward amendments at stage 2. However, the accompanying response has indicated that there are still a number of areas and a number of specific points that we have made where the Government has yet to be persuaded. Persuasion is, of course, what committees are all about and I will lay out some of those areas where I hope ministers will think again. As the cabinet secretary has said, the bill seeks to ensure more integrated workload and staff planning across health and care. The question for the committee has been whether it will ensure appropriate staffing levels to deliver high-quality care in both health and social care settings. Part 1 of the bill establishes the guiding principles for staffing. That applies to the bill as a whole and the committee agrees that those principles should work to ensure equity and parity across all staff groups. Most of the evidence supported those guiding principles and few would argue with the aim of providing safe and high-quality services. The bill will, as has been indicated, replace existing methods for assessing the adequacy of staffing levels. Professional judgment is part of the current staffing methodology. It is not yet a part of the bill. We are pleased that the input of professional judgment should be much more prominent on the face of the legislation. Workplace leaders are best placed to take decisions on what staffing requirements are on any given day and whether there are enough suitably qualified staff on duty to meet patient needs. The committee agreed—of course— Askel Hamilton. I am very grateful to Lewis MacDonald for giving way. Does he agree with me that the professional voice is not just important when it comes to safe staffing, but the best ideas for best practice can stem from the ward level and be disseminated outwards as best practice for the whole country? I absolutely agree with that. It is fair to say that the approach that the committee has taken to the legislation and other things has been to seek as broad an input from professional groups as possible. I hope that that will be the approach that is taken both by NHS management and by the Government in taking forward this bill. As I said a moment ago, we agreed that the bill should reflect existing practice and give a prominent role to professional judgment. We also concluded that the judgment of allied health professionals and social care workers, as well as the judgments of nurses and midwives, should be considered in order to achieve equity and parity across services. Clearly, all staff groups involved in delivering care should be involved. The Government's policy memorandum says that 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 service users and people using care. We can all clearly agree with that. Our report suggests that clarifying the role of professional judgment should be part of the bill and strengthening the commitment to staff wellbeing in the provision of safe and high-quality services. I was pleased a few moments ago to hear the cabinet secretary commit to bringing forward an amendment in this area at stage 2. Many of our witnesses from the caring professions asked for these principles to be made clear on the face of the bill. Those changes would not weaken the bill. In the committee's view, they would strengthen it. Although the Government believes that the bill will support increased integration of health and social care services and that that is a desirable outcome, providing a consistent framework for staff planning across the sector, we also did hear considerable evidence of concerns that it could inadvertently have the opposite effect. Some witnesses suggested that the bill is at risk of separating out health and social care and of not including significant groups of staff. That could imply that different expectations would continue to apply to different parts of a system, which the Government and all of us in other contexts say should be seen as a whole. We also heard concerns that the bill was very much process-focused at odds with the priority of the integration agenda of providing better outcomes for patients. We are keen to ensure that the bill's focus on process would not be at the expense of outcomes. We would take the view that that should be in the general principles of the bill. The Government's response, accompanying the cabinet secretary's letter, said that an outcome focus in the general principles of the bill would represent unnecessary duplication. I was surprised to read that, and I am sure that the minister will think further about that before stage 2. Jeane Freeman also mentioned healthcare improvement. Scotland is undertaking work as part of its excellence and care approach to provide information on expected staffing levels and actual staffing levels by ward. That is now happening in some places. The committee agrees that it is a good idea to roll out that initiative nationwide. Again, we would encourage the minister and the Government to consider whether that could not be done. Part 2 of the bill applies the general principles to NHS staffing in particular. Health boards are already required to do workforce planning and to ensure the provision of high-quality care to support those duties. A suite of 12 workforce planning tools has been developed and, as we have heard, they have been developed over a period of time since 2004. The committee decided that we should survey health boards to find out about the use of existing tools. We found out that the use of existing tools was patchy. Boards have been subject to a mandatory requirement by the Scottish Government to use those tools since 2013, but that has clearly failed to have the desired effect. The bill would replace a mandatory requirement with a statutory requirement. We asked the Government how that change would deliver compliance in the future. The cabinet secretary's written response this week has noted that a number of measures are already in place to monitor health boards' compliance with the legal duties and suggests that no change to monitoring will be required. It is frankly difficult to square that with the current inconsistency in compliance, and it would be useful to hear more about how a statutory duty will differ in practice from a mandatory requirement. Although the workforce planning tools have been in use for up to 14 years, we also heard concerns around levels of training provided. Witnesses were keen that staff should have dedicated time to attend training rather than be expected to acquire expertise as part of continuous professional development, and it would be useful to know whether the Government agrees with that. Part 3 of the bill relates to staffing in care services. The policy memorandum notes the purpose of including care services in the legislation is to allow the sector to build on and strengthen existing statutory mechanisms to create a cohesive framework across all health and care settings. The bill provides a power for the care inspectorate to develop workforce planning tools for application in care settings, where our need is identified and agreed. Much of the evidence that we heard on part 3 of the bill questioned whether the bill was actually necessary in social care services. Those are clearly provided in very different environments from hospital settings, and we recognise that that must be factored into the development of any new tools. However, we concluded that the care sector should not be treated differently from the NHS. In both, we should expect enough suitably qualified staff to be present to deliver high-quality services, and patients and their families will expect no less. The Government made clear to the committee that the staffing methodologies in the bill are not linked directly to national workforce planning, although the national health and social care workforce plan is mentioned throughout and indeed was mentioned by the cabinet secretary this afternoon. Other witnesses were concerned about how the outcomes of the bill could be achieved without a firmer link to wider national workforce planning. If there is insufficient labour, skilled labour, available nationally to full vacancies, health boards and care services may be unable to meet the requirements of the bill. We need to know and they need to know what we then follow if that is the case. One concern raised was the possible skewing of resources away from social care at the time when tools exist only in the NHS. Staff and other resources might be concentrated in the acute sector in order to meet the statutory requirements under part 2 of the bill, while tools are still under development for social care under part 3. A similar issue was raised by all ed health professionals who were concerned that directors of finance could be put in an invidious position when it came to deciding priorities. Funding might go to the nursing side, for example, at the expense of AHPs and of multidisciplinary working. We need to ensure that those fears are not realised by ensuring that the essential role of AHPs is reflected in the legislation, particularly for the early years before part 3 of the bill comes fully into effect. Again, an amendment at stage 2, as was indicated by the cabinet secretary today, would be widely welcomed. The committee unanimously supports the general principles of the bill, while seeking clarification on the issues that we have raised and a positive response to the concerns that we have highlighted in our report. Many of the witnesses to our stage 1 inquiry were looking for reassurance that the Government was listening to their concerns. I hope that the cabinet secretary will reflect further on our report on the debate and on the concerns that are raised by witnesses so that we can see the bill made much stronger and better at stage 2. I thank all the organisations that have provided useful briefings ahead of today's debate. The most valuable resource of any organisation is its people, and our Scottish NHS is no different. There are over 162,000 NHS employees across Scotland who work tirelessly day in day out to deliver and support our health and social care services for the people of our country. The question that they are asking is, what exactly will the bill do to help to support those working in Scotland's health and social care settings? For me and for members of the Health and Sport Committee, those have been the questions that we have been asking ourselves from day 1. I hope that the committee report has been useful to the Government in trying to move forward questions around that, and specifically the unintended consequences of the bill. To answer those questions, we need to look no further than the RCN member survey on staffing. Last year, RCN Scotland carried out a survey of its members, and the survey had 3,000 responses from care and support workers across Scotland, delivering some very concerning responses. 51 per cent said that the last shift was not staffed to the levels planned, and 53 per cent said that the care was compromised as a result of that. 54 per cent reported that they did not have enough time to provide the level of care that they would have liked. 47 per cent said that they felt demoralised. 61 per cent of respondents worked extra time on average 46 minutes at the end of their shift. Over a third said that because of a lack of time, they had to leave unnecessary care unprovided. Most importantly from the survey was the statements from NHS staff and their world view of what the current workforce crisis is in Scotland. I have picked out three points that were made by NHS professionals. The only reason that we had enough staff today is because we had bank staff. We had enough staff for the patients, but in mental health we have attack response situations. No, for most of the night, we would not have been able to assist staff if the colleague had been under threat of physical violence. When you are short staffed, the workload is the same, you have to get round everything, you are consistently chasing your tail, you are anxious, you are rushed, having the right staff, changes that. All of us in this chamber know and recognise that our NHS staff go the extra mile every day of the week to deliver the care that we value so much, but what tools can they have at their disposal when the environment and wards that they work on reach unsafe levels and the risk that that puts to their safety and the care of patients on that ward? I wanted to outline in the time that I have today some of the areas where I think that the bill does need to be improved. In relation to process, the Law Society of Scotland stated that stage 1's guiding principles were too general. They fear that there could be a scope for subjective judgment leading to inevitable juggling of compromising and competing priorities. Some stakeholders were concerned that the bill could undermine care by focusing on process and narrowly defined settings rather than outcomes. I think that that is what we certainly heard at committee that it is making sure that our health service is outcome focused. In relation to accountability, the bill places a general duty to ensure appropriate staffing on health boards and care service providers. It will be health boards, commissioners and providers who will be accountable. One of the key concerns that we heard and raised with us was the need for greater clarity on where accountability will sit within the bill. If no one is named as an accountable officer, there is a risk responsibility at the level of people who are running those tools, but who will become exposed to adverse events arising and how that is fed higher up into the NHS management structures is something that many members are still not completely clear on. It was professional judgment that I thought was also a key part of what the bill should also see to improve, and we will be seeking to improve. Witnesses called for the input of professional judgment to be more prominent in the bill. I welcome some of what the cabinet secretary said. It was felt that professionals had to be involved in the process with views taken at a local level, below executive and senior management level, as has been outlined by the committee's convener. While professional judgment is part of the new common staffing method, it is not included in the bill. The Royal College of Nursing believes that it is essential that the bill enables the empowerment of nurses. I agree, and as the cabinet secretary has outlined, the opportunities that the bill can present, I hope that we can really make sure that we realise to empower our NHS staff and staff working in our health and social care settings. The bill is aimed at ensuring that there are adequate staffing levels where health and social care is delivered. As Alex Cole-Hamilton stated, the bill could provide a much-needed focus on workforce planning. With regard to the social care setting, this is still a key area where the Government and the committee would like to see more clarity on how the bill will impact and how those tools will be developed and delivered. I note ahead of today's debate the concerns and reservations that were expressed by COSLA, SCVO and others with regard to the bill's proposals in a social care setting. Social care amounts to more than a quarter of the third sector's turnover, and 34 per cent of voluntary organisations in Scotland are involved in delivering social care-related activities. The provision in the bill relating to social care and the development and introduction of standardised workforce tools to the sector currently has no single governance structure and is made up of hundreds of diverse organisations. That is clearly going to represent a major challenge and something that I hope the Scottish Government clearly will bring forward more work on and to build confidence and support in the sector. I welcome much of what the Scottish Government and the Cabinet Secretary's response to the committee outlined yesterday in her letter to the Health and Sport Committee. The unintended consequences of the bill have been outlined by many organisations ahead of stage 1 today, and I hope that, as we see the bill progress, we can look to address some of those. To conclude, Scottish Conservatives recognise that our health and social care workforce face a number of key challenges. With or without legislation, unless we urgently resolve the staff shortages across NHS Scotland, safe staffing levels will remain a dream rather than a reality. The cabinet secretary states in her response to the committee that the bill is about workload planning, not workforce planning, but for those who work in our NHS and social care services, those are of the same thing. We need to see progress in addressing the staffing challenges in our health and social care services. As Karen Hedge, Scottish Care's national director, told the committee that the bill will not magically create nurses, we need to be clear that working to deliver a full staffing complement must be the number one priority of the Scottish Government and of the Scottish Parliament. Scottish Conservatives support the general principles of the health and care staffing Scotland bill, and we will work cross-party to amend the bill as it progresses through Parliament. I now call Monica Lennon to open for the Labour Party to be followed by Alison Johnstone. I am pleased to be opening for Scottish Labour in this debate. I thank the Health and Sport Committee for its carefully considered report. From listening to the convener, Lewis MacDonald, it is clear that the committee went to great lengths to gather evidence and to scrutinise the health and care staff in Scotland bill. The committee's recommendations reflect that rich body of evidence, and I agree that the Scottish Government would do well to remain open to persuasion, because there clearly is some room for improvement. Some of the committee's recommendations have been reinforced in the many stakeholder briefings that we have gratefully received ahead of this debate. This has been a milestone year for health. This summer, the chamber and the country came together to mark out NHS at 70, and we had a lot to celebrate. Our health service has saved and transformed countless lives. All of us in this chamber will have a close personal affinity with the NHS. Moving forward, the integration of health and social care has the potential to be transformative. However, there are underlying challenges that we must get to grip with in order to reduce the levels of ill health and health inequalities that persist. Under this Government, we are not yet seeing enough progress on that front. The cabinet secretary said that we are living longer, but we are not yet living healthier lives. That matters because all of us have a right to health and want to live good, healthy lives. It is also a matter of urgency because our health and social care services are struggling to cope. The cabinet secretary and her response to the committee's stage 1 report says that the Scottish Government understands the pressure that staff are facing. We know that the cabinet secretary has inherited this bill. I am not convinced with all the pressures that the NHS is facing. That is perhaps the bill that she would have wanted, but I know that she is sticking with it. Scottish Labour will play her part to improve the bill and strengthen it. We are eager to work with the cabinet secretary and her team in the widest terms possible. However, as we debate the health and care staff in Scotland's bill today, our focus has to remain on outcomes and what difference that legislation could make to the health and wellbeing of our constituents and our loved ones. Scotland's health and social care workforce is working tirelessly to provide the very best of care. It cannot work any harder. It is far from easy. Miles Briggs has talked already about nursing, and we know, according to the RCN, that there are times when staff are just not able to meet the needs of their patients due to staffing shortages, issues with the skill, mix of teams and ever-increasing demand on services. In the past few weeks, I have seen this first hand, as my own mum has spent far too much time in hospital, so none of us are detached from that. It is very real and it is happening now. It must concern the cabinet secretary that Audit Scotland warns that the NHS in Scotland is not financially sustainable and that its performance continues to decline. Today, we have had another section 22 report on NHS Tayside, and it is extremely serious. We have a health board that is facing perpetual financial crisis, and the buck does stop with the Scottish Government. I am grateful to Ms Lennon to take an intervention. In order to make sure that we have the absolutely correct context, I am sure that Ms Lennon will agree with me that the section 22 order on NHS Tayside refers to the last financial year and that the Audit Scotland report by the Auditor General's own acknowledgement did not, because it could not at that point take account of the medium-term financial framework that I published. In order to make sure that we are getting an accurate picture of the current state of play, perhaps we just need to add those extra bits of context in. I am glad that the cabinet secretary put on the record her medium-term framework, but there is no denying that, again, we have a very serious report from the Auditor General, and I am sure that the Audit Committee will pick that up and scrutinise that in due course. Currently, in the NHS, there are enough job vacancies to fill to Scottish hospitals. The BMA says that the true number of consultant vacancies is double that of the official figures from ISD. Scottish Care points to a shocking 32 per cent vacancy rate in nursing and social care. The Royal College of Physicians of Edinburgh says that unless staffing gaps are resolved, safe staffing levels will remain a dream rather than a reality. What will the bill do to address the staffing crisis? The cabinet secretary is clear that the bill is about workload planning. It is not about workforce planning, but put simply, there must be enough staff available to deal with the high workload that NHS staff are experiencing. There is plenty of work that the Scottish Government has underway, and I look to the public health minister and the work that he is focusing on in relation to alcohol and drugs. All that is really important, because, to go back to my earlier remarks, this is about prevention, and we have not seen enough preventive action to reduce the pressure on the NHS. The bill is hopefully part of a wider, new, radical approach to health and social care workforce planning that is person-centred. From unison to the BMA, the message is really loud and clear that just putting existing duties into statute is not going to change anything by itself. The committee stage 1 report highlights several areas of concern about the bill that are in highlight the importance of on-going monitoring and the escalation of risks. If safe staffing levels fall below the requirement, there must be a quick, clear and effective route to escalation. Those tools must work in real time, so that if any health professional who finds himself on an understaffed ward can alert that problem. We have had dozens of briefings. For example, the Royal College of Physicians and the Royal College of Speech and Language Therapists highlight the importance of workforce planning supporting the new multidisciplinary models of care. I am getting to closure. The bill aims to give parity between health and social care by setting out staffing justices and care services. However, we have heard from COSLA, the Coalition of Care and Support Providers and the SCVO that they are all concerned that the bill is unsuitable for the care sector and could undermine integration. We have to be alive to those concerns. I know that my colleague Alex Riley will want to say more. In conclusion, Scottish Labour welcomes any efforts to improve safe staffing. We support the general principles of the bill, but the bill will not fix health and social care workforce crisis by itself. NHS staff are facing burnout. I was grateful to the cabinet secretary for taking my intervention on that point earlier. I know that she takes those matters very seriously. In terms of social care, that sector needs to be overhauled because conditions are quite frankly not good enough for many social care staff. Scottish Labour believes that health and social care should be focused on— No, no, no. When you say, in conclusion, I think that it means something to us, not in conclusion, here comes another chapter. In conclusion, we focus on the outcomes and we will work with the Government and others. That is absolutely— And then we must just secure that. Thank you. Thank you very much. I know that trick. I have used it myself. I now call Nalisyn Johnson to open for the Greens, please. Thank you, Presiding Officer. The Greens support the general principles of the bill and will vote accordingly at decision time. However, it is clear that there have been sufficient concerns raised by many groups, including the Royal College of Nursing, allied health professionals and COSLA, that we needed to encourage the Scottish Government to continue to give those careful consideration. It is not surprising that there is a well-established link between safe staffing levels and the delivery of good quality care. A study by Professor Ann-Marie Rafferty found that both patients and nurses in hospitals with favourable patient-to-nurs ratios had consistently better outcomes than those in hospitals with less favourable staffing ratios. Patients in the hospitals with the highest patient-to-nurs ratios had 26 per cent higher mortality, while the nurses in those hospitals were twice as likely to be dissatisfied with their jobs, to show high burnout levels and to report low or deteriorating quality of care on their wards and hospitals. That being the case, it is concerning that Scotland continues to experience on-going challenges in the recruitment of health and social care staff. Audit Scotland reports that vacancy rates for nursing and midwifery staff rose from 2.7 per cent in 2013-14 to 4.5 per cent in the last year. Currently, 30 per cent of nursing, midwifery and allied health professional vacancies remain open for three months or more—an increase of a quarter on the previous year. Although there has been a national increase in nursing and midwifery staff over the past four years, numbers of staff in the year to March 2018 have fallen in some health board areas. If nearly 20,000 nursing and midwifery staff responding to the 2017 i-matter staff experience survey, barely a quarter said that there were enough staff to allow them to do their jobs properly, with less than half saying that they were able to meet all the conflicting demands on their time. The provisions of the bill may well play a role in ensuring that our health and social care staff services are appropriately staffed, and Greens welcome the guiding principles for health and care staffing, respecting the dignity and rights of care service users, ensuring the wellbeing of staff and being open with staff and service users about decisions relating to staffing are all welcome principles. The duty of health boards to ensure staffing is appropriate for the health, wellbeing and safety of patients. That is welcome, but I welcome the cabinet secretary in closing to elaborate further on the Government's intention to further extend the duty to cover the wellbeing and safety of staff. Below adequate levels of staffing have an impact on the wellbeing of staff, as well as the patients. I know that we are all agreed on that matter. The survey of staff presented in the Nursing Against the Odds report paints a concerning picture of the physical and mental toll on nursing staff when staff levels are below what is needed. An A&E nurse surveyed said that, because of low staffing levels and lack of resources, they felt exhausted, stressed and dehydrated. That is consistent with the 51 per cent of Scots nursing and midwifery staff surveyed who reported feeling exhausted and negative. I also asked the cabinet secretary to consider whether the terms health, wellbeing and safety could be more explicitly defined, and I draw attention to the stage 1 submission from NHS Orkney, which said, The perception of what is safe and what has been agreed may differ, and we need to ensure that this in turn does not become an area of tension between staff and managers. The duty on health boards to report on how they have ensured proper staffing, followed the common staffing method and how they have trained and consulted staff is welcome. However, could this be made more specific with boards having additional requirements to report where the duty has not been met? Although individual board reports would be welcome, accountability might be improved if there was a responsibility on the Scottish Government to collate a report covering all boards until later this before Parliament. That would allow for transparency, consistency of reporting and therefore better public scrutiny. The Royal College of Nursing, with others, is seeking a wide range of amendments to the bill, and I look forward to working with them all as we move to stage 2. I encourage the Scottish Government to continue to engage with those bodies on the issues that they raise. In particular, I would like to focus on enabling senior nurses to discharge their management duties fully by being non-case load holding and to add provision, allowing nursing staff to undertake continuous professional development. On the inclusion of the care sector, that is a crucial issue on which there is clearly not yet a clear consensus. I note in particular the very strongly worded statement released by COSLA, which says that the Scottish Government has yet to demonstrate that the bill will improve outcomes for people in receipt of care and for social care staff. It is important that we note that the provisions of the bill will only play a small role in ensuring that there are appropriate levels of staffing, and many of the briefings that we have received have raised issues relating to the scope of the bill. If it does nothing to address supply and availability of trained staff, then boards and social care providers alike will find it difficult to meet the duties that would be placed upon them. The Royal College of Nursing has questioned whether the legislation can be, and I am quoting, implemented fully and in a way that will improve the quality of care that patients receive without significant investment, particularly in the workforce and without recognition of the reality of current workforce pressure and with likely future increased demand on services. In closing, I ask the cabinet secretary to outline what investment is being made in the health and social care workforce and how the bill sits within a broader strategy to address the supply of staff. I would ask her to consider the RCN's suggestion that there should be a duty on the Government to ensure that there is a supply of nursing staff that is sufficient to meet current and future demand. Thank you very much. I now call Alex Cole-Hamilton from the Liberal Democrats. Mr Cole-Hamilton, please. Thank you very much, Deputy Presiding Officer. It is my privilege to offer the support of the Liberal Democrats for the general principles of the health and care staffing bill, and treading, as I do in the footsteps of my friend and colleague, Kirsty Williams, who, as a Liberal Democrat assembly member, stewarded a very similar piece of legislation through the Welsh Assembly some years ago. It is important, whenever we talk about staffing, to reflect how much we rely on our NHS staff, not just our NHS staff but those working out in social care in the community and our allied health professionals. Particularly at this time of year, they deserve the thanks of a grateful Parliament and a grateful nation. It is important and incumbent on any committee charged with the consideration of a piece of legislation to ask the first question at the top of that consideration. Is that needed? I was really struck by a conversation that I had with Sarah Atherton, who works for the Royal College of Nursing. When I asked her exactly that question, she relayed to me a conversation that she had had with a senior nurse on a psychiatric ward when she asked, were you safely staffed last night? She said, well, there's two answers to that question. Yes, we had enough staff to treat our patients, but because we have to operate on an attack response basis, we were not safely staffed, because we did not have enough staff should something have gone down, should some crisis have happened. For me, that epitomises why the bill is needed. For years, we have ignored the anxieties and expertise of staff on the ground. Often times—and I think that this is a fair criticism of all parties who have held government in this country—financial targets have often held priority over safety. There are many examples that we all probably know which mirror the example of that psychiatric ward. In this bill, we are offered the opportunity not only to fix the numbers, but to ensure that we get the right balance of skills and experience in every staff team and in every care setting. With the right skills mix and the right number of staff, we have an empirical link to safer outcomes. We need more on the face of the bill, I believe, to link methodologies, tools and practice to outcomes and draw that golden thread right through. That's why I'm very grateful to hear the cabinet secretary's remarks this afternoon about strengthening the professional voice within the bill, to listen and to act on the suggestions of those at the chalk phase. Innovation, as I said in my intervention, comes from the grass roots most of the time and best practice is germinated in those wards. We need the staff voice, but we also need clear accountability. We have always regarded it as a slight gap in the bill. Accountability needs to be held at several levels. When everybody's job to make sure something happens, it suddenly becomes nobody's job to make sure something happens. I absolutely endorse what Alison Johnston said earlier about the idea that senior charge nurses should be non-caseholding and should have that strategic overview and, as a clinical leader, not counted in the headcount of a safe staffing cohort. Every care setting, whether that is in acute or non-acute or in the community, should be encouraged to catalogue and display their staffing levels so that they can benchmark success and aspire to greater things. However, having somebody unencumbered by operational issues is absolutely vital for ensuring that accountability. We need to trust the expertise of our staff. We are blessed by some incredibly gifted staff. It is the recognition of that correlation between staff wellbeing and patient safety, which is vital. I fear that there is still scant detail as to how that has achieved in the bill, ensuring that staffing cohorts in any care setting are supported by them psychologically in terms of stress and in terms of stress management. I think that there is a direct causal link to what we are doing in the ongoing discussion that the chamber and the committees of this Parliament are having about whistleblowing to ensure that our staff are supported and that we are supported to raise concerns as well. When we talk about staff, we are not just talking about nurses. I think that there was initially a slightly myopic view that the bill was just about nursing for all their strengths and the fact that they have driven the agenda. I thank them for it, but they recognise that that has to encompass social care staff and, indeed, allied health professionals. Each of those professions provides a vital and important part to every patient's care pathway. In particular, we talk about delayed discharge in the hospital and the lack of social care provision. That care pathway can cause an interruption and flow throughout the entirety of the health service, so it is important that those professions that do not necessarily have the methodologies that are established as the nursing profession are afforded the space by the bill to grow those methodologies and their own toolkits to interconnect with the methodologies of their multidisciplinary colleagues. Finally, I will close in this way, Presiding Officer. As with child poverty, and I said this to the cabinet secretary as well, as with the child poverty bill, you cannot just legislate and make something happen. You can legislate for aspiration, but you have to back that up by culture change and empirical policy change on the ground as well. We have to recognise that the bill will not end nursing shortages or the social care staff in crisis in our communities. The bill will not be solved by this bill, but it is an absolutely vital part of the jigsaw for ensuring that it is a sustainable, safe and attractive profession for people to come into. It is part of that drive to increase provision within those sectors, nor should attempts to deliver in one sector safe staff and come at the expense of another. That was my other intervention, ensuring that we are not just having a gold-plated service in a safe staff and culture in acute sectors at the expense of community settings and non-acute settings as well. It is equally vital in patient pathways. The bill is needed and it will enjoy the support of the Liberal Democrats tonight. Open debate, speeches are six minutes as usual, but there is some little time in hand for interventions, which I would encourage. Emma Harper, to be followed by Annie Wells. We are here in chamber to debate and hopefully agree on the general principles of the health and care staffing bill presented by the Government. As deputy convener of the Health and Sport Committee, I would like to start by saying that I agree with the general principles laid out in the bill and I support the Government's motion today. I was a new MSP for the south Scotland region when the First Minister announced the Scottish Government's intention to enshrine safe staffing into law at the Royal College of Nursing Congress in Glasgow in June 2016. I was a new MSP, had just been providing direct patient care as a clinical nurse educator for NHS Dumfries and Galloway just a month before the First Minister's announcement. I enjoyed my work as a nurse educator and as a peri-optive nurse and my 30 years of clinical experience in America, England and Scotland has helped to inform me in the scrutiny of the proposed bill at stage 1. Along with colleagues, I would like to acknowledge the amazing work that all health professionals who provide care across health and social care 24 hours a day, seven days a week. The people who are the professionals are truly amazing. The committee has taken evidence from a range of stakeholders since the bill was introduced in May this year. Stakeholders such as the Royal College of Nursing and all health professionals, the BMA and COSLA and others, I thank them for their input. There are issues in the bill that need to be addressed and I would like to bring the attention to the following. I would like to highlight that the purpose of the bill is to set out the principles for ensuring that there will be appropriate staffing to deliver high-quality care to patients, clients and service users across a complex care system. The intention is to enable an evidence-based approach to provide safe, efficient and person-centred care. It is important to be clear that the bill does not focus on national workforce planning but the bill includes a focus on the development and application of workforce planning tools. Some of those tools have not been developed yet. That was something that was raised in evidence from the allied health professionals who appeared at committee. One of my former colleagues in the NHS of recent Galloway was very clear with me that that bill must include the whole multidisciplinary team. As the integration of health and social care progresses, we really need to make sure that all specialties who are providing care, whether in primary care, acute care, care in home environments or in the community, are included in that legislation as it progresses. I am interested in the development of the workforce planning tools. We have heard that current common staffing methodology uses a triangulation approach and includes workforce tools of professional judgment, as well as specific tools aimed at areas such as operating room or neonatal intensive care units, for example. There is a difference in delivering care in rural south west Scotland at Galloway community hospital compared with Glasgow and Edinburgh, the city centres, where trauma services and different specialty acute care delivery is essential. I was interested to hear in the evidence that the development of new tools may take up to 10 years, but I note that in the financial memorandum there are two further tools that are in development and more will be developed within five years. I would like to ask the Scottish Government what work is being done currently to perhaps speed up the process of development of appropriate tools, especially with allied health professionals across multidisciplinary teams. What work is being done to actually develop the tools in a perhaps more timely way. I know that it can take a long time to implement change in the national health service as being a nurse with a whole family of nurses can attest to as well. The fact that we are currently pursuing an integrated health and social care system will really take on board the fact that many different types of professionals support health and social care needs across Scotland. I welcome the briefing submitted from the Royal College of Nursing, the Association of Anesthetists and the Royal College of Physicians, as well as others. Yesterday, when I spoke with the senior RCN representative, I discussed the RCN's proposal to allow for senior charge nurses not to have their own caseload, therefore allowing them to focus on supporting the co-ordination of care, support and management of staff and other time-consuming duties that they are responsible for. I welcome Alison Johnston's comments because she is saying the similar thing about supporting the work of the senior charge nurses to not have their own caseload. That applies across many of the health care situations that we work in. I support that in principle and recognise that there will inevitably be instances where senior charge nurses will provide direct patient care, such as in the operating theatre. However, the principle of charge nurses having no direct caseload is one that I support. I would like to see the Scottish Government explore options of this as we move forward with the bill. I have been in the operating room where everything is going smoothly until the aorta was punctured during a straightforward minimal invasive surgery procedure. That is when the professional judgment and immediate ability to react to the fast change in life-saving situation is paramount. Flexibility must be built into the legislation, flexibility to allow immediate staff and judgments to be made. I know that the bill takes into account the professional judgment tool that has been described in both written and face-to-face evidence from experts at the committee, which I welcome. I welcome the bill and I would like to put my thanks on record for all those who attended sessions at the committee and indeed all who have been involved in the process. I would like to thank the Scottish Government to take a look at some of the issues highlighted, including the senior charge nurses and their workload, and I look forward to participating in the progress of the bill. The importance of NHS staff goes without saying and, at some point in most of our lives, we will have had our lives changed for the better thanks to the personal dedication of those providing the high-quality care. We understand the immense pressure on staff who work under extremely difficult conditions, sometimes at a detriment to their own health, making this bill all the more important. Although the Scottish Conservatives support the bill in principle, we have concerns shared by a number of organisations. At stage 2, as my colleague Miles Briggs has said, we will look to strengthen the bill through amendments focusing on giving professionals a strong voice and making sure that decision-making data is robust and up-to-date. One aspect of the bill that I want to focus on is its value of the importance of staff well-being. It is clear that staff are being pushed to their limits and that staffing shortages are taking their toll. As we have heard from Monica Lennon as well today, in the past three years, the number of NHS staff absences due to staff suffering stress has increased by nearly 18 per cent, resulting in more than 1 million working days being lost. In Glasgow, the increase in absences is even higher, at nearly 25 per cent. What is clear is that staff are struggling to cope, and I am pleased to see the importance of staff well-being being a guiding principle. I really hope that the bill can in some way provide the basis to which we can improve the current situation. However, it is worth mentioning that the majority of witnesses raised their concerns that the bill is being introduced at a time when workforce is under pressure from a general recruitment and retention problem. Statistics are currently showing, for example, that hospitals are short of 2,400 nurses and mid-wise, and that NHS wards are in need of 750 more doctors. I thank Annie Wells for taking intervention. I am sure that she will have read the report from the committee and she will realise the concern among the witnesses about the effect of Brexit, both currently and in prospect, and how much role that plays in the recruitment issues that they are currently facing. Does she agree? Annie Wells I thank Keith Brown for the intervention. What I would say is that this has not just happened overnight, which is something that the concerns have been raised for quite a while. We have to look at it in the longer term, because we do not just need 750 doctors in the past two years. The Royal College of Nurses and Responses of the Bill stated that it was important not to tie the hands of boards and put a duty on them to provide appropriate staffing if the supply issue, which is held by the Scottish Government, is not dealt with. In the third sector of the voluntary, the Scottish Council for Voluntary Organisations has expressed concern that, given 34 per cent of voluntary organisations in Scotland are involved in social care-related activities, additional duties placed upon organisations cannot be considered in isolation of the resource provided. Link to this, greater clarity must be given on where accountability lies, a concern noted by the Chartered Society of Physiotherapy. A general duty has been placed on health boards and care service providers to ensure appropriate staffing, but if no one is named as an accountable officer, senior charge nurses and team leaders will be left exposed should an adverse event arise as a result of shortages in staffing. That was supported by those in the care sector. Unison Scotland highlighted the precarious situation of accountability, given the fragmentation of delivery of care services. And who will be responsible for safe staffing levels and reporting on them within the third sector? That will be especially difficult to answer when care provision is commissioned from a third party. Although we support the principles of the bill, the Scottish Conservatives believe that it is vital that professional judgment plays an important role. I am pleased to hear the cabinet secretary address those points earlier. As the Health and Sport Committee's comments have been made, it is believed that professionals had to be involved in the process with views taken at local level to take account of the day-to-day dynamic staffing of health settings. Existing tools must be made to accommodate absence levels, differing staff skill mixes and the needs of patients. As stated by the Royal College of Nurses, without nurses of appropriate seniority exercising professional judgment each day, safe staffing levels will not be reached. The SCVO has stated, given its importance in delivering social care, that it too must be consulted on legislative proposals. As well as the need for staffing models that allow decisions to be made on the ground, we also want to make sure that decisions are made based on the most accurate of data. Amongst the moving feasts of real-time decision making in wards and across community teams, healthcare professionals need to be confident that they trust the reliable and up-to-date data. It is only through that strategic decisions can be made to enable safe, high-quality care and services. To finish today, I would like to again express my support for the principles of the bill. Ultimately, that is a bill that puts an existing but enhanced workforce planning method on a statutory footing, with principles that are unobjectionable. We all want to see the highest quality of care given to patients consistently across health boards, with the wellbeing of staff always in mind. At stage 2, the Scottish Conservatives will work cross-party to submit amendments that seek to strengthen the bill, and I hope that some of the comments that are made today will be taken on board. I call Keith Brown to be followed by Alec Rowley. Just to mention the aim of the bill, which is to be an enabler of high-quality care and improved outcomes for service users in both the health service and care services by helping to ensure appropriate staffing for high-quality care. It is important to do that, because we have started off with a balanced and fair account of the committee's work from the convener, Lewis MacDonald. The debate has gone to a number of other areas, related and quite legitimately, but it is important to bear in mind what the purpose of the bill is. For me, it is the latest development in the efforts that we have made to try to drive the high standards in our healthcare and by everybody in the health and social care sectors, and to make best practice a standard that is to be achieved across the board. As the policy memorandum states, the aim of the bill is to provide a statutory basis for the provision of appropriate staffing in health and care service settings, thereby enabling safe and high-quality care and improved outcomes for service users. The 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 service users and people experiencing care. From my point of view, we referred general support for the general principles of the bill. I found it a little bit odd with some of the witnesses that came before the committee when asked if they supported this, said they did not support it and they did not see any way in which it can be improved. I think that a particular thing that concerned me was the idea, especially those who quite rightly focused on the needs of the care sector. To my mind, that presents an opportunity to ensure that we have the right staffing so that it strengthens the arguments of those who want to see improved staffing in the care sector. I am not sure on what basis people would not want to support that, by all means seek to improve it, but at least support the aim. The aim does mean that, at a strategic level, the planning of staffing within both our NHS and the associated social care and care home provision is taken in such a way as to maximise the effectiveness of the resources that are available and to deliver for our clients, and to ensure that their experience of health and care must always be our paramount consideration. We have to ensure that the systems that are put in place in this regard should help to ensure that the practices within health and care in Scotland are the best that they can be and in doing so that the patient experience is a positive one. In relation to the issues around recruitment, it was quite evident that there are, and have been building for some time, pressures because of Brexit. I could not evidence this from what we heard, but I think that probably more acutely in the care sector than the health sector, but in both sectors. Those pressures are building day on day, week on week, month on month, a very substantial issue in terms of recruitment. It is mentioned, for example, that it is part of 206 on page 34, when it says, Brexit uncertainties mean that it is challenging to meet the existing requirements and staffing establishments that are currently set by health boards and social care providers. In specific terms, the bill itself is intended to deliver a number of things. The promotion of safety in the health and care sector is at the heart of the bill, and that also means safety both for clients and for the health and care staff themselves. The mechanism for delivering this is by creating a statutory duty on staffing levels and applying those to territorial and special health boards. Such a mechanism would require appropriate staff planning and risk management to be undertaken. During the recent round of consultation on the bill, the committee asked stakeholders for views on that and how the bill could best achieve that. In its submission, my own local health board, NHS Forth Valley, stated that the positive outcomes for patients and staff must be at the heart of the decision making process. The workforce tools will run consistently with health and social care boards having to act upon the results. The NHS Forth Valley also proposed the need for a formal reporting structure to be part of any process, and it was among a number of consultees who stressed the need to clearly identify who is responsible for undertaking us. I have some sympathy with that. The one thing that I would say is that, in relation to outcomes and talk of sanctions and targets, many of us stand up in the chamber and talk about the problem of bureaucracy in the health board. There is a real danger that we can create new forms of bureaucracy here. It is very important that, as we go through the different stages of the bill, we bear that fact in mind. Clotmanusure and stilling health and social care partnership also commented on the general principles of the bill, stating that it welcomed the guiding principle of a rigorous, transparent approach to decision making about staffing in health and social care. That is what we should be aiming for. If, at the end of that process, people can point to deficiencies or ways that can be approved, then the bill is achieving its purpose. For example, Clotmanusure and stilling health and social care partnership also said that there are concerns regarding additional expectations on planning and commission departments, but that should be a good thing. If there are additional expectations on the commission departments, that should help to address some of the perceived issues in relation to staffing in those sectors. There are entirely fair concerns to raise at the stage of the consideration of the bill, but I welcome the general acceptance from the many consultation responses that are submitted that the principle and the direction of travel of this bill is the right one. In our detailed consideration of the bill, we have to take cognisance of those views. I also think that the points raised in the briefing sent to MSPs by the Royal College of Nursing were valuable and, given the central part, RCN's members will play in dealing with this when legislation is enacted. I think that it is certainly worth considering the points that they raised for a moment. They raised six tests. Just before Labour and MSPs got too excited, it was nothing to do with Brexit. They were looking for positive outcomes, putting staff at the heart of decision making, which I think that the bill seeks to do. It tries to get the professional judgment. Somebody called it subjective judgment. We are looking for the professionals to make a judgment on this. That is the vital part of this, and I believe that the cabinet secretary gave assurances both today and at the committee when she appeared before that suggests that that will happen. It is really important that it does. I welcome the general principles of the bill. I also welcome some of the points made by a number of members. It strikes me that there is a good basis on which to go forward in relation to this bill, not least because the cabinet secretary has given her assurances, first of all in her response, and by saying that she intends to listen to what has been said as we move through that process. With that kind of co-operation and constructive engagement, we can get the right bill at the end, so I am happy to support the bill. I thank Lewis MacDonald and the Health and Sports Committee for producing that detailed report, which I think will be very useful moving forward to stage 2. I know that Jeane Freeman, the Cabinet Secretary for Health and Sport, issued a response to that last evening. I have not a chance to read that properly, but again, I think that it will be useful moving forward. I take the point that Keith Brown makes about focusing on the purpose of the bill, and he says that it is about appropriate staffing and safe staffing. However, it is a bit like the emperor's clothes. If you do not have the staff, then appropriate and safe staffing will be difficult to achieve. It reminds me a bit of legislation in which you legislate to give people a treatment guarantee. You recognise that having a treatment guarantee does not guarantee people treatment when they actually need that treatment. Therefore, the very question of what legislation purpose is for is something that, legitimately, we need to ask in terms of this bill and perhaps some other bills that are making their way through Parliament at this present time. I note that the Royal College of Physicians raised a few issues. They say that legislation alone will not fill the rotagaps and vacancies in the workforce. The recognition in paragraph 97 of the policy memorandum that there are currently significant challenges in recruitment in both health and care service settings needs to be addressed. I think that we really do. Yes, absolutely. I am grateful to Mr Rowley for taking the intervention. I am sure that he will acknowledge that I have never, at any point, said that this bill will automatically, by itself, produce the numbers of professionals across health and social care that we need. However, what it is is an important additional tool to help us to have a workforce plan as well as we can. Getting the information via the application of the legislation to ensure that we have robust evidence in order to identify how exactly we should continue to increase the numbers that we have in training, in nursing, in medicine and in our allied health professionals. It is one of the tools that we have. It is not the automatic silver bullet to fix the problem. I think that Monica Lennon acknowledged that when she opened for Labour and said that we in principle support this bill, we need to do quite a lot of work on it. There are some serious questions that have been raised by the third sector, by COSLA and others, that need to be addressed going into stage 2. Nevertheless, I am sure that, as parliamentarians, we all know that our constituents out there are asking the question, what are we actually doing about the staff shortages that ensure that people do not are not guaranteed the healthcare they need when they need that healthcare? If you look, for example, in Fife at the current time, there are seven practices in Fife that are registering as being in difficulty, a high-risk situation. NHS Fife says that they cannot recruit the GPs. There are practices where they are having to close their lists. There are currently 16 practices that are full. That is not just about accessing GP services, as the cabinet secretary knows. That is about accessing a whole range of community health services that would be part of a holistic health service. Those services are struggling right now, and my constituents are saying to me, what are you doing about that? I ask myself, where does the legislation provide that support? I think that we need to be honest with the public and we need to start addressing the big issues that are in health at the present time. COSLA makes a point in terms of social care. COSLA, by the way, has produced a two-page briefing that is highly critical of the current legislation. I think that we need to address that moving forward, but the bill is poorly timed as the social care workforce is experiencing challenges in terms of recruitment and retention. I would say that we need to look at social care. I think that Monica Lennon spoke earlier about 70 years off the NHS. The NHS in 2020 is going to be looking a lot different from what was established back in the late 40s. I do not think that we have asked the question and looked at what does a modern day national health service in Scotland look like. Part of that is social care, and that is why we would not necessarily sign up to what COSLA has to say about social care being separate. However, the fact is that social care is provided through local authorities and health boards. It is provided through the third sector, and that is why we have so many third sector organisations coming in here with concerns, but it is also provided through the private sector. One of the major problems in recruiting for that social sector is lack of job security, poor pay, poor terms and conditions. What would a national health service look like in 2020? A national health service is not built just round about hospital buildings. A national health service is caring for people in their own homes. However, why should that workforce be on the minimum wage or the living wage when other parts of that workforce are paid a more decent pay and have decent terms and conditions and have job security? What does the workforce of the national health service look like moving into 2020? Should all those social carers be part of the health service, or are we going to allow the modern health service to be split into a private sector provision that pays lower wages, terms and conditions? We need to invest in our workforce, and we need to ask some fundamental questions about what that workforce looks like moving forward. I say to the cabinet secretary that Labour will work on that, but we think that we need to be more bolder, more radical in looking at what a modern health service in Scotland looks like. Thank you very much, Mr Rowley. I call Sandra White to follow by Edwin Mountain. Thank you very much, Presiding Officer. I take this opportunity to thank my fellow members on the committee and the witnesses and, of course, the clerks for their guidance, certainly to me and others, and the hard work that they have put into getting to this stage one of this report. This bill's remit is intended to cover staff planning in health and social care services, with aim that staffing in both sectors is organised and planned to ensure appropriate staff are in place by providers to enable them to deliver safe and high-quality care, and also, of course, the safety of staff, which is paramount. Alex Cole-Hamilton made an important point—I think that he made an important point and also Emma Harper made this point as well—in regard to, yes, at the very beginning, the RCN was seen to be the driver of this particular bill, but it was quickly recognised that this bill is not just about acute services, it is quickly recognised that it is about all health and care providers, and they all had a part to play, and in particular to further the health and social care integration, which I think is really important. I thank the members for raising that as well. I am the RCN for recognising that it did not just cover acute care. In my contribution, I want to concentrate on the integration of health and social care. I note the concerns of COSLA, and I picked up what Alex Rowley had already said, but when you look at some of the issues that he raised, one of the issues that he said is that the bill is a potential threat to the integration of health and social care. I think that it is rather sad that they have used that as a headline, and I am sure that the health committee will look to that, and I am sure that the cabinet secretary and the minister will look at that. I think that the integration of health and social care is paramount to get healthcare that we want, which everyone else has spoken about. As I said, it is not to me just about acute care, and I do not think that it is that to anyone else either. I do not think that we should be focusing on acute care alone. I do think that we need to look at the integration of health and social care and other members. Alex Cole-Hamilton mentioned that in relation to a cultural change. We need to see a cultural change, and that was certainly raised by witnesses to the committee. If there is even debating on the bill at this stage, there could be a starting point for people to listen to. There should be a cultural change within the various providers. I want to turn to the evidence that we received today. I thank the cabinet secretary and the Scottish Government for the replies that they gave to us. The first one was a 194, and it is staffing and care services. We have made a recommendation and we can see the attractions and advantages from treating all parts of delivery of health and care in the same manner. We can see no rationale to ultimately treat the sector any differently from the NHS. Both are providing services to the public, and the public should be assured that they and their relatives are being looked after adequately with care for personalism and dignity. I thank the cabinet secretary and the Scottish Government for replying to that. In the reply to the Scottish Government's responses, it is our intention that the development of any new tool on mythology would be carried out in a similar manner in the way in which the existing tools were developed into health. A clinical reference group is established prior to the development of any new tool, and all health boards are invited to contribute to the clinical reference group. I hope that that allays some of the fears that COSLA has raised in any other allied health professionals in that regard. I think that integration is one of the great things that we can move forward with the bill. I know that it is a work in progress, but it should be one of the areas that we should absolutely be covering. I am a little selfish in mentioning that. I am the convener of the cross-party group on older people, age and ageing, and we have had lots of interest from our members and discussions and organisations regarding the integration of health and social care, particularly in the provision of community care and care homes and the staffing of those. In fact, the cross-party group will be hearing from Brian Slater, head of partnership support within the health and social care integration directorate of the Scottish Government next week at our cross-party group. I am sure that the members will be interested to hear what we have had to say in this debate, and also what Mr Slater has to say about the progress that is being made with integration. I know that cross-party group members will be looking to find out what the implications are perhaps of the staffing bill, the stage 1 bill that we have at the moment, and what the levels will be, particularly as we are dealing with an increasing ageing population and the pressure that they have on the system. I think that it is important that we look at that particular one. As I said previously in my summing up, I understand that the stage 1 bill is very much a work in progress, and I look forward to being here and seeing as it progresses through Parliament, and hopefully we can come to stage 3 of the bill. We will all agree with it, and even COSLA and others will say that integration really is something that is very important and that the staffing bill is not just about acute services, it is about all of the care provision in health and social care as well. Thank you very much, Presiding Officer. Thank you. I call Edward Mountain to be followed by David Torrance. Thank you, Presiding Officer, and I would like to join with my colleagues here in supporting in principle the health care bill. I would like to also start at the outset by thanking the committee for their in-depth report. I know how much work goes into them. I would also like to reiterate a word of caution that has already been raised this afternoon for the Government, and that is to quote the Royal College of Physicians in Edinburgh. You cannot legislate staff into existence. Making new laws can identify work frameworks and targets for staffing, but frankly we need actions on recruiting to make the bill meaningful. Let us look at another bill if we could in relation to this. The Patient Rights Act sets down a 12-week treatment guarantee into law. This is workload planning or should have been when it was established, but the problem is that it is a law that many of my constituents in the Highland is broken on a weekly basis, if not a daily basis. I mentioned in passing that we found out that two constituents this week have waited 72 weeks—that is 72 weeks—for chronic pain treatment in NHS Ireland. Frankly, that is not acceptable. I think that the Scottish Government, except that legislation alone will not reduce waiting times and legislation alone will not resolve the recruitment crisis affecting our NHS and that this bill will not ensure the greater delivery of service. However, I think that the health and care bill can make a difference, but only if it is used as part of a wider range of measures to tackle workforce planning across our NHS. If the bill does make the difference that it needs to do, it needs to be strengthened significantly. We have already heard from my colleague Miles Briggs that the Scottish Conservatives will be lodging amendments to ensure that professionals are given a strong voice in the staffing process based on workloads and to ensure that the decision-making process data is robust and up-to-date. I think that that is critical. Why do these amendments matter? We believe on the side of the chamber that hard-working doctors and nurses know perhaps better than anyone what it comes to make safe staffing levels to deliver the service that is required, but I believe that their voices have often been ignored when they have raised this in the past. Let me give you an example if I may of where the workforce planning is failing. In August 2017, over 50 doctors and consultants signed a letter to the board of NHS stating that the crisis in radiology staffing is so acute in the highland that it has reached an unprecedented level. Do you think that that would be a clear warning on workforce planning and delivery? I will come back to you, Mr Brown. A year on, I would just say that the situation is far worse and NHS has been with no substantial interventional radiologists in post. That means that patients are needing to travel to NHS Tayside and Grampian, and I think that that is frankly unacceptable. I think that that is a failure of workload planning that has come about because of poor workforce planning. I thank Edward Mountain for taking intervention and saying that he commended the work of the committee and the witnesses to it. One of the issues raised by the witnesses was the issue of Brexit, particularly if I recall right in relation to radiographers. Does he concede the point that Brexit, especially in rural areas of Scotland, is having a detrimental effect on recruitment in the NHS? Edward Mountain? It is all very easy to find something that is going on at the moment to blame for the problem. For me, the problem goes back for a lot longer than that. It goes back to poor workforce planning, probably up to 10 years ago. If the First Minister was here in the chamber, I would ask her about that as well. I do not believe that there has been enough planning not only by the Government but also by, in the case of my constituency and region, is the NHS Highland to resolve the problem. Speaking privately to healthcare professionals, which I do almost on a weekly basis, they have come to the same conclusion as me. Hopefully, what this bill will need to address is how to make safe staffing levels possible to deliver the services that are required. It is a question of which to put first. I believe that doctors and nurses know what are required to produce the service that they are required. I believe that the problem is that they are often constrained by those in administration who believe that they know better. We also know that when staffing levels are low, pressure on existing staff increases. That leads to unrealistic expectations that with reduced numbers, the same service can be delivered. It cannot. That often leads to unrealistic demands that become overbearing and unachievable, causing staff to feel bullied and undervalued. The result is that they leave. It has also become clear that that leads to problem with recruiting. Let me give an example. The orthopedic department in NHS Highland has not functioned for two years. The OMFS department has not functioned for three years. It is definitely needed, identified as a problem, but there is no one there to manage it. That, to me, creates a perfect storm. I am worried that the bill went to address that in its current form. That is why it needs amendments and strong input from those on the ground, not just those in offices. I also believe that the bill needs a provision in it that protects the welfare of our staff. Not to do so to me would be a failure. I will be looking, hopefully, with members across the chamber, but certainly with my colleague Miles Briggs and colleagues on these benches to find a suitable amendment that takes this into account. I support the bill knowing that it does not go far enough at this stage, but, with amendments, it can perhaps do that. It is, at the moment, to me, not sufficiently aspirational or inspirational, but I believe that there is a really good opportunity with proper amendments that should come from across this chamber to make it both of those. I call David Torrance to be followed by Anas Sarwar. Thank you, Presiding Officer. I would also like to say thank you to everyone that has contributed to the process, particularly committee clerks for all their hard work, healthcare professions and the representatives that gave up their valuable time to participate in our evidence sessions. NHS Scotland's workforce is growing and the plans upon our health and social care sector has never been greater. We need to be flexible in relation to those demands. We have seen an increase in consultants by 48.3 per cent and an increase in training places by 5.7 per cent of qualified nurses and midwives with a further 2,600 training places being created by 2021 and an increase overall workforce growth of 9.5 per cent since 2006. Currently, staffing levels are set locally by health providers. This bill does not seek to change this by prescribing the minimum staffing levels or fixed ratios. This legislation will continue to support local decisions, which is flexible and has the ability to redesign in a way across disciplinary and multi-agency settings. The issue of staffing levels is not new, as the Royal College of Nursing states in her staff guidance. What is the optimal level of mix of nurseries required to deliver quality care as cost-effectively as possible? It is a perennial question. Further on that, in order to forecast the workforce required to meet further care needs, workforce planning also needs to consider a changing balance between types of care and the different models of delivery to be anticipated. This legislation will provide a constant process with validated workload and workforce planning tools, which will help to support our healthcare workers as they continue to provide world-class care to patients. It is widely recognised that although it has been mandatory for health boards to utilise the tools and methodologies since 2013, there are inconsistencies in the way in which the tools are applied and the extent to which existing methodology is utilised to make informed decisions about staff requirements. Enshrining this process in law would help to ensure a more constant approach to staffing across all service areas and, in turn, contribute to better outcomes for patients and provide the public assurance that the right numbers of staff are in place to deliver personal-centred care. I very much welcome the comments of ANGAL, the healthcare improvement Scotland, during the committee's evidence session that she stated. I really shall not matter what the social sector people are looked after. We should be entitled to good care and high-quality outcomes and to be assured that the right levels of staff will be in place to look after them. It is vital that we have the right number of staff with the right knowledge and the right place at the right time to provide safe and effective care. I would also like to thank Heron Wright, NHS 5 director, executive director of nursing, for taking the time to share our thoughts about the bill directly with me. The most important people in the process are those that work in our health and social care services. It is imperative that the development of staffing methods are professionally led and are developed in a collaboration with the sector if we are to successfully deliver a robust sustainable statutory framework. The safety of patient care must be paramount and we have to focus on delivering high-quality care through a systemic and responsive approach for determining staffing levels. Having an effective and stable staff team is a backbone of delivering high-quality care. An injective of Evanston's Bay statutory process, which builds upon the current model, integrated with professional human judgment, will better equip services with tools that are flexible and can take into account the very needs of the sector, without becoming an obstacle to either integration or innovation, therefore by restricting the opportunity of varying standards of care that exist across different services or, indeed, different areas of the service. A number of members have mentioned the difficulty and recruitment in the health and care social sector this afternoon. Therefore, I consider it important today to highlight the current threat to health and social care sectors from Brexit. At this point, business as usual, beyond next March, it is anything but certain as an invaluable contribution of EU workers all across Scotland being jeopardised by outconceived and short-sighted immigration policies of our UK Tory Government. The figure shows that there are 26,000 people from the European Union working in health and social care, and I will do it in public administration in Scotland. I am grateful for the member for taking this intervention. The committee, as he will know, also heard concerns around the policy of new recruits being sent instead of into adult social care, into child social care and the impact on workforce planning that has had. We have also heard that Nicola Sturgeon and her spectacular error of judgment of cutting the number of trainee places has also impacted on our health service. Would you also like to highlight those points as well? I thank the member for the intervention. Just now, at Brexit, it is taking the impact right now. When you see a UK transplant surgeon who has committed over 1,000 operations leaving because he cites Brexit as a problem, and when you see specialised doctors dropping to an eight-year low because he breaks it right now, we have real problems with it, and problems will come in the future about it. We have already seen that as an important impact on the recruitment and retention of EU nationals. As the Brexit shambles continues, it will have a very real and far-reaching implications for health and social care. A contribution of EU nationals to our workforce cannot be underestimated. Both our health and social care sectors will face considerable shortfall if there is any restriction to EU migration and changes to residents' rights of EU nationals will have a significant impact on the sustainability of our health and social care sectors. We will have a long relied on EU nationals across all areas of our healthcare system, and as the demands upon our services increase, we will continue to need them in the future. It is a very real threat to our social care sector, which cannot be ignored as uncertainty hangs over adult social care putting further stress on our services. Conclusions, Presiding Officer. I would like to thank everybody involved in their work in the committee, and everybody who supported it, and I fully support the principles of the bill. Anna Sarwar, followed by Alex Neil. Thank you, Presiding Officer. Can I start by putting on record, like the cabinet secretary and many other speakers that are, thanks to all our NHS and social care staff who continue to go above and beyond increasingly difficult circumstances, so I sincere thank you to each and every single one of them. But our thanks isn't good enough, they need more. Staff are clear and staff representatives are clear that they feel they are under extreme pressure. They feel there are too few of them to deliver the care that they would like to give to their patients, and they do fear that patient care is compromised due to a lack of staff. In short, they feel overworked, undervalued and under resourced. At the same time, while public appreciation for the NHS and the staff is rightly high, it is also the public's number one concern. I would like to write the outset that I accept that those are not problems of Jean Freeman's making, and she still has to accept that her Government has been in power for 11 years, and that she now has the responsibility to fix those problems. We support the principles of the bill, but I believe that it needs major surgery. I also sincerely believe that, if the cabinet secretary was designing the bill at the outset, I think that it would have been a very different bill indeed. She said that this is about workforce load rather than workforce planning. I think that both are interconnected. If you do not have adequate levels of staff, it means increased workload on existing staff. I would like for the bill to be more than just a PR exercise, I am sure that that is also an aspiration shared by the cabinet secretary. However, we have to accept that the bill will give not one extra member of staff and does not itself solve the workforce crisis. I know that the cabinet secretary does not like the term workforce crisis, but we have to accept reality. We are 3,500 nurses and midwives short in our NHS, 540 allied health professionals short, almost 400 consultant posts short, 1 million stress days lost by NHS staff, 100 million pounds a year being spent on medical locums, 25 million pounds a year on private nursing agencies. We have to be honest, if that is not a crisis, then what is? What the bill needs alongside it is a credible and deliverable workforce plan. It needs adequate training places. It needs a recruitment and retention strategy. We need to look at how we can bring the vacancy rate down and we also need to look at how we can reduce pressure on existing NHS and social care staff and help boost their morale. However, we also have to accept a fundamental issue and problem. We cannot magic up the people. 3,500 nurses and midwives, 540 AHPs, 393 consultants and more. In the acute sector alone, that is close to 5,000 people short. If we add the social care sector volume, many more thousands on top of that, we will simply not find the 5,000 plus people that we need right now. We have to have an honest and serious conversation about what we can deliver, how we can deliver it and how we find the right skills mix to deliver an NHS fit for purpose. I want to give some practical suggestions about additions that I would like to see to the bill. First of all, I emphasise the point that Alex Rowley made. That cannot become like the patients right act, which is all great in principle. We all agree on, but, in reality, it does not fit the word guarantee. That is why I think that the bill does require some serious amendments. First of all, I note that SAFE is no longer part of the title or in the bill, but who actually decides if a ward is safe? What happens if a ward is not safe? In the circumstance where a ward is not safe, the ward manager has a decision to make. He cannot employ a member of staff straight away. He will turn to agencies more often than not. That means a risk and increasing agency fees. He can shut the ward, although I doubt that is what we want or that it means closing of beds. In those circumstances, if a ward is judged as being safe but is in a difficult circumstance or is judged as being unsafe but continues to operate, that has some severe risks for existing NHS staff. If you look at the Bawa Garba case in particular, staff are under increased pressure and are worried about the implications of an adverse incident and who is held responsible. We need to define what is safe and build into the legislation protections for staff. We also need, I think, more robust data. What data will be made available through the bill to allow greater scrutiny in this Parliament but also greater public scrutiny? I have already mentioned agency staff. I think that the bill should go further. I think that we should look to cap agency fees. I am not talking about the overall amount of health board spending on agencies, because that will have unintended consequences. I am talking about how much an agency can charge for a shift or how much it can pay out for a shift. Let me give you some examples. We have already heard in the Audit and Skills Committee that there are examples of medical consultants being paid up to £400,000 in a single year. We have already heard from Audit Scotland that, on average, an agency, full-time equivalent agency nurse, costs three times the amount of a single NHS nurse. If we take that into connection, that is one agency nurse to three NHS nurses and one agency consultant to four NHS consultants. I think that the cabinet secretary will look seriously at whether we should have an amendment in the bill that caps how much an agency can charge for a shift and how much an health board can pay out for a single shift. I also think that we need to go further about scrutiny and sanctions. What sanctions are there on financial sanctions? I am talking about accountability on health boards. There should be written into the bill that health boards should have to publish if they fail to meet their obligations through the bill. There should also be built into the bill a commitment from whoever the cabinet secretary is at any given time that, if the intention of the bill is not met, the cabinet secretary will come to the Parliament and make a statement in detail why those have not been met and what steps the cabinet secretary is taking to address them. Finally, I noticed my time. I think that there needs to be greater coordination with social care. I accept COSLA's concern about social care being separate, but if we are truly to talk about integration, we cannot isolate social care. We have to look at integration of health and social care. We have to be cautious that we do not go back to thinking about doctors and nurses and midwives but recognise that we need a multidisciplinary team, particularly if we cannot find the adequate levels of doctors and nurses. How do we build into the legislation a greater protection for the multidisciplinary team? Those are all areas that need exploration from the next time that this bill comes to the Parliament. I hope that this will be an opportunity that the cabinet secretary works with the political parties to deliver a truly transformative bill so that we can have an NHS fit for purpose for the future. Deputy Presiding Officer, it is very good that we have a general agreement across the chamber on the principles of the bill. There is a wide recognition that the role of the bill is not entirely to solve the problem but, as the cabinet secretary rightly said, is an additional tool in the box to help to solve the problem in planning and implementing a workforce development plan. There has been a lot of talk about acute services and about the care sector, but we should emphasise that the bill also covers the primary sector, and that is extremely important. It is important, because 90 per cent of all the patient contact with the health service is through the primary care sector. Secondly, we are planning quite rightly, and I think that we have cross-party support in that, to shift the emphasis from acute care into preventive care and primary care and social care in the community. A lot of that and some of the ideas came from Alaska. The reason that I mentioned Alaska is not just because that was the source of quite a number of the current reforms in the primary care sector that we are implementing, but because in Alaska they have carried out a very successful reform of their entire health service as a result of which they have ended up closing down some hospitals because they now provide so many services in the primary care sector that there is so much reduced demand on the acute sector that they no longer need the number of hospitals that they started with. That is clearly a good thing, because it is never good to have to be treated in a hospital. Your chances of catching infection and all the rest of it, even with a very successful patient safety programme, are still a lot higher than it is in the primary care sector. The point that I am making is that, in planning the workforce, you do not just start by looking at today's vacancies and saying that this has to be the workforce plan to replace or find people for these vacancies. That is part of it. What matters is the demand forecast for the future profile of services that is going to be required. We should base our workforce plan on our estimates of future demand, not on existing vacancies. Alex Rowley I thank Alex Rowley for taking an intervention. I am aware of the last model because Councillor Andrew Roger, who has been on NHS Board for many years, has championed it. However, the difficulty is that that transformation is getting the resources into the community side, into the primary care, while still maintaining the acute side. The idea that the Government has that the money will somehow just go across and the demand will fall off has not happened. Does he agree that there needs to be some bridge in place to resource community care much more to take the pressure off acute? Alex Rowley I make two points. First, the set-asite provision, which was in the integration bill, has not worked as well as it was planned to work. We all know the reasons for that, but that was the intention. It was the modern equivalent of the bridging fund that was used when previously we were emptying the Victorian so-called asylans to treat people in the community for mental health issues. Secondly, if we get every penny of the Barnett consequentials that we are supposed to get as a result of the substantial increase in health spending planned for south of the border, I would imagine that a fair proportion of that would go into building up the primary and community care sector facilities that we need in order to shift that balance from acute into the primary and community care sector. However, I absolutely take the point and I think that the set-aside way of doing it has not worked as well as the bridging funding method that was used when we were modernising mental health services. I am sure that that is something that the health secretary will be looking at in terms of the future, but there is no doubt at all that we have to look at the profile of what health is going to be like in three, four, five or ten years' time. A brilliant project has just been announced jointly between the health secretary and the University of Glasgow two weeks ago, a £15 million project, in looking at how artificial intelligence can improve prevention and diagnosis. Part of that will be that in some time in the future, although it is not too distant in the future, we will be able to identify what disease people will have before they show the symptoms of having the disease. The manpower requirements for that are completely different from the manpower requirements of the way that we do that today. In fact, your first priority would be to get people who can operate artificial intelligence. Clearly, at the moment, there is nothing in the workforce plan that I would imagine for artificial intelligence engineers and the like. That is a very good example of where we should not be thinking of a workforce plan in the narrow sense of filling existing vacancies. It needs to be about providing for the 21st century leading-edge health service that we are planning. Scotland is ahead of the application of artificial intelligence and other associated technologies as it applies to the health service. I hear all the concerns and the moans and the groans on a daily basis, but sometimes we have to start shouting about the things that we are doing really well in Scotland. Being ahead in those technologies is one of the huge benefits that we have in our health service. The £15 million project will, I think, transform things even further. However, that is how we have to think about the workforce. The workforce in five years' time, in terms of numbers, in terms of locations, in terms of job descriptions and in terms of training requirements, will be completely different from what it has been in the past five or ten years. We are all agreed that we need to plan accordingly. The bill is an additional tool for the health secretary and the health boards, including the primary care and acute sectors, to help us to get it right. I am sure that, if we do it on the basis that I have suggested, we can never be absolutely accurate in workforce planning. Anybody would tell you that, but as long as the direction of travel is right, then we can get it as close as dammit to right. Bill Bowman, followed by Bob Doris. I welcome the health and care staffing Scotland bill in principle. However, it should be acknowledged that there are important points that should be raised and are being raised in this debate. I suspect that I may repeat some of them. In its programme for government 2017-18, the Scottish Government committed to introduce a safe staffing bill during the 17-18 parliamentary year to deliver on the commitment to enshrine in law the principles of safe staffing in the NHS. Those commitments resulted in the health and care staffing Scotland bill being produced to enable safe and high-quality care by making the provision of appropriate staffing in health and care as statutory requirement, resulting in better outcomes for service users. The bill covers both health and social care services with the aim of ensuring more integrated workload and staff planning. The broader approach is noted as seeking to ensure that there will be appropriate staffing to deliver high-quality care whatever the setting. It is important to be clear that the bill does not focus on national workforce planning, as has already been mentioned. The bill includes a focus on the development and application of workload planning tools, aiming to ensure that health and social care providers are providing adequate numbers of suitably qualified staff to provide safe and high-quality services. The Scottish Government has overall responsibility for NHS workforce planning. However, it should be noted that the Scottish Government has decided on the numbers of most health service staff entering training, but not necessarily those entering the allied health professions such as occupational therapists. The Scottish Government undertook two consultations on the proposals in 2017 and 2018, and the general feedback was that the proposals seemed too narrow and there was a fear that the focus and resources would be directed at nurses and midwives, rather than at all groups such as occupational therapists, for example. Additionally, the proposals did not consider safe staffing in a system-wide way in the context of national workforce planning and training numbers, nor in the context of current workforce challenges. It currently does not provide guidance on how to identify, monitor and mitigate staffing risks in response to differing daily needs. Additionally, that must go further to strengthen the role of the nurse to make professional judgments in regard to staffing. The subsequent consultation on proposals that took account of earlier responses and focused on how the legislative framework would cohere across health and social care ran for four weeks in February 2018. Respondents felt that any new methodologies should work across health and social care, that there should be flexibility in how new tools were developed, used and reviewed, and that there should be recognition of the new challenges that are faced across sectors in recruiting and retaining staff. The finance committee also issued a call for views on the financial memorandum of the bill and it received several responses. The issues raised and included lack of training costs, costs associated with reviewing the staffing tool and costs to other social care providers. It is pertinent that we use all of our resources wisely and the goal of the health and care staffing Scotland bill should be to do just this. We can all agree that a well-researched and evidence-based staffing framework would be ideal to ensure that the right staff are helping the right patients. It would have a legislative framework for health boards that appears methodologically sound. That would include the use of specified staffing and professional judgment tools, consideration of quality, local context and risk and a requirement to report on how they use the tool and methodology when making decisions about staffing requirements. For example, what might be right in nine wells in my region might not be right for Strachathro. However, the bill provides no concrete examples of how legislation will actually achieve this. The Scottish Government claims that this practice is based upon methods implemented by nurses and midwives yet fails to produce data that demonstrates the success of this method, which this method had with caregivers. If this bill were to be effective, it must call for constant reporting. That would not only maintain data to measure effectiveness but also ensure that the guidelines are followed. It is important to consider how the bill will deal with the real problems of staff shortages and budget cuts in planning teams. There has been very little information about the costs of implementing those changes. The social care workforce is currently experiencing challenges in terms of recruitment and retention. We must be sure that the bill will not add further processes and pressures to a system that is already under strain or increase the reliance on agency staff and undermine the financial stability of the sector. A move to a new system will create new upfront costs before any of the promised savings can be realised. Although it is already the duty of health boards and care service providers to ensure appropriate numbers of staff, the guiding principle of the bill is acceptable. Having the right people, as has been said, with the right skills and the right place at the right time to ensure the highest quality of care and outcomes that are delivered across health and social care is a principle that we all share. The Scottish Government is undertaking a reform of the planning system 12 years after the last reform. However, it has been clear from the beginning that there are problems in planning caused by cuts to budgets and staff shortages. The Royal College of Physicians and the Royal College of Nursing Scotland both raise concern that staff shortages are a key issue. As others have commented, it is resources not reorganisation that they need. The last of the open debate contributions is from Bob Doris. Thank you very much, Presiding Officer. I have not been involved in the scrutiny of this at stage 1. I do not sit on the health committee, but I did note that the policy memorandum says that the policy intention of the Scottish Government is to enable a rigorous evidence-based approach to decision making relating to staffing requirements. The stage 1 report notes that the overall aim of the bill is to ensure safe and appropriate care of staffing levels based on a clear evidence-based methodology that is regardless of setting. I think that those underlying principles that we all agree with, as I certainly strongly associate myself with those intentions. Some interesting parts of the stage 1 report that came to my attention are recommendations in section 57. We believe that there must be more clarity on where accountability for the provision of appropriate staffing in health boards and care service lies. Although the policy memorandum advises that it will lie with organisations, we believe that unless there is a named accountable officer, there is a high likelihood, particularly in health board settings, for those at ward level to be held or feel accountable. That is very important. I note that the cabinet secretary said that clarity on the ground in NHS awards to the country will be important. I welcome the assurances to the committee relating to that it would sit as corporate responsibility compliance with the health board. It also further notes that, for example, it would expect that the senior nurse would run the current adult inpatient tool. I am not sure that that is full clarity, to be fair. On the ground, there is no exact science regarding safe staffing levels at any particular snapshot in time. I declare an interest to my wife as a nurse. Clinical coordinators on the ground will use significant data more generally to determine the required staffing at any given time. Even things such as football games and large events in a city, for example, ICWeather, predicted and trends over the past few years, peaks and troughs and demand, whether that has safe staffing level implications for accident emergency units, for HDIU, for ICU and beyond, predicted demand and surge demand—that all has to be fed in to the mix. Depending on that demand, the complexity and the type of condition that nurses in particular often have to deal with, you see a regular transfer of nurses between wards and you often have to make a decision as a nurse whether it is safe to have a nurse transferred from your ward or not. You will also be the same token as a nurse on the ground. You might have to decide whether it is appropriate to take an additional patient into your ward. Do you have safe staffing levels to allow you to do that? Do you have safe staffing levels to allow you to allow a nurse to go to another ward whether they are experiencing surge demand? That nurse in charge is not always a senior charge nurse, although I appreciate the final decision that will be taken by a senior charge nurse. At every layer of the NHS organisation within hospitals, professional judgments have been exercised. At some point, for corporate compliance, the buck has to stop somewhere, and I think that greater clarity on that would be required. There is some positivity around that as well, because when there is conflict between a nurse in charge saying to a senior charge nurse that they do not think that it is advisable that they take an additional patient, for example, on that ward or where the senior charge nurse might disagree with the board in relation to what professional judgment and safe staffing levels look like, that is an opportunity to review and revise and enhance the work road and staff planning tools that exist, but I think that we need clarity about where responsibility sits. I want now to turn to the care sector. I think that that is a powerful extension that will strengthen the sector, particularly the third sector. Avid care homes in the third sector say to me in my constituency before that the national care home contract has been unfair towards them. They have asserted that it gives preferential treatment to council care homes. They say on occasions that services procured in the third sector in terms of social care are not always funded as appropriately as a local authority setting might be. Surely developing and agreeing what a multidisciplinary skills mix would look like, yes, with professional judgment, but what that would look like in the care sector would be a key strength in relation to that third sector having those negotiations with councils and integrated joint boards. I think that that is to be welcomed in terms of that level playing field across the care sector irrespective of where care is delivered. Most of all, just as a son whose mum was in a care home, I was very fortunate that it was a wonderful care home. The building was old, but the staff were fantastic. If you want to ask that question, feel empowered to ask the question in relation to, well, how do I know that there is a safe staffing mix in here and you are given some general reassurances that that is okay, that your mum or your dad or your brother or your sister has the suitable care and skills mix there? You have much better reassurance if you know that there is a robust, consistent, reliable and evidence-based safe workload planning tool to ensure the correct skills mix. That does not exist consistently across the country right now, so it is not just about empowering the care sector, it is about empowering staff in the front line to say, actually, we do not believe staffing requirements are sufficient and you have to do better, but in the care sector in particular it is about empowering families to make sure they are sure that their loved ones are suitably looked after. I welcome the general principles of the bill that we have debated here this afternoon. We move to the closing speeches, and I call David Stewart for around six minutes, please. Thank you, Presiding Officer, and I believe that this has been an excellent debate with insightful and well-informed speeches from across the chamber. As a member of the health and sport committee, I was present and took active part in the questioning of all our witnesses, including the cabinet secretary, so I feel that I have some background in this particular debate. If I could paraphrase the conclusion of our stage 1 report, which many other members have mentioned earlier today, to paraphrase it, it was that no one can object to the guiding principles of the bill, which, of course, is about having the right people with the right skills in the right place at the right time to ensure the highest quality of care. As we have heard earlier, Labour supports the general principles of the bill, but as Monica Lennon, Anasawa and Alex Rowley made clear, there are areas of concern, which we believe, if the dress could strengthen the bill. The cabinet secretary, in response to the health committee stage 1 report, which I got this morning, said that the bill is about workload planning, not workforce planning. Critics might argue that this is about how many angels can dance on the head of the pin, and many territorial boards in Scotland, such as my own in Highland, have a workforce crisis. Anasawa talked about the consultant being employed for £400,000 a year, a horrendous amount of money that, in turn, fuels the flames of financial instability. Scottish Labour believes that health and social care policy should be focused on achieving the best outcomes for people and protecting staff wellbeing. As Coslat has argued, the overlines on processes could make the bill just another bureaucratic box ticking exercise, but I have heard the cabinet secretary say that she is bringing some amendments at stage 2, and I believe that other members will as well, so there are opportunities to strengthen the bill. I would also like to put in record that we need to learn lessons from history. As I have reported when I spoke a few weeks ago about in our bullying debate in NHS Highland, we need to look at what the Francis report said when it looked at bullying and bullying in NHS England. It concluded that losing trained talent from the NHS led to inadequate staffing levels and poor quality of care. As we know from the stage 1 report, we have a set of 12 workforce planning tools that have been developed for nursing men with free. The committee, as the cabinet secretary will know, had a survey. If I just quote a couple of the responses, it said that the tools were not helpful in community setting, time-consuming and not sure how the tools can help to develop safe staffing for patients. A third of survey respondents had received no training on how to use the tools and there was no consistency of how training was delivered. As Audit Scotland said, there is a risk that the time taken to train affected staff could put extra pressure on the workforce and impact on services and quality of care to patients. It has been a useful debate that kicked off obviously by the convener of the committee, Lewis MacDonald, who talked about the constructive suggestions from the committee on a unanimous report and mentioned the views of allied health professionals that need to be listened to in the whole debate. There was some evidence gathered, as the cabinet secretary will be aware, that perhaps the bill is currently too process-focused. Miles Briggs made some very good points about the crucial point that is self-explanatory, which of course people are the most valuable asset in the NHS. What will this bill do to those working in health and social care at the front line? The very useful RCN survey gave some very useful raw materials to us all. Just about every member made the obvious point that has to be said that NHS staff go the extra mile every single day to help patients. My colleague Monica Lennon talked about the fact that, yes, we are living longer, but are we living healthier, particularly if you look at health and equality within Scotland? How a focus on outcomes is key and made the very interesting point that if you look at the vacancy level in the NHS currently, it could fill two mudged-sized hospitals. Alison Johnstone made an excellent point about the links from research between good, safe staffing and favourable health outcomes and touched on the 4.5 per cent vacancy level for nurses and midwives. Many members made at this point that surely the Scottish Government has a duty of care for the wellbeing of all staff. That might be mentioned in some legislation historically, but perhaps, cabinet secretary, that might be an amendment for stage 2 that you look favourably from the committee on. Alex Cole-Hamilton started with a rhetorical question about whether the bill is needed and stressed the importance of protecting hard-working staff on the front line and the key about getting the right balance of skills and experience. Anna Salwar made an interesting point in my view about whether there should be a cap on agency staff costs that the cabinet secretary will hopefully look at. In conclusion, on the very front side, I was reading the other day from the British medical journal and Dr David Oliver, who is a consultant in acute general medicine, said that, without adequate staffing in clinical roles, NHS performance will decline and services will come unsustainable. Moral will worsen and staff will leave or choose to do less—a vicious circle. Finally, as Naib Evan would have said on that quote, you do not have to gaze into a crystal ball when you can read an open book. Before I start, I refer the chamber to my register of interests in the IT company, developing communication and collaboration platforms for sectors, including the healthcare sector, but I am not receiving any remuneration for this post. I have a close family member working in the Scottish NHS. I think that it is a very good debate today and an extremely important one given the subject. Initially, when the bill was brought forward, it was called the safe staffing bill and the fact that the word safe has been dropped with all the connotations that that would have meant if the safe staffing bill level had not been met. Anna Savard mentioned this. If we are going to have levels of safe staffing by default, we will also have unsafe levels of staffing. That probably tells you how important the bill is. What it does do is allow us to focus on our healthcare professionals, their health and the quality healthcare that we receive from the NHS. The guiding principles and overall purpose is to reassure someone in hospital or in social care that they are receiving that safe and high-quality care. There was a concern within the committee that the integration of health and social care, which is already well under way, could be negatively affected by the bill. I think that the cabinet secretary would like to reassure the committee that this can be avoided. Edward Mountain is right in his summation that the welfare of our healthcare professionals, although he mentioned in the bill that he said the same thing, does not state how that will be achieved. Given the ever-increasing demands on health and social care, as the cabinet secretary herself alluded to, we in this side of the chamber have consistently stated that, when it comes to creating an environment where patient outcomes are a priority, looking after the health of our healthcare professionals must be the very first step to consider, as Mary Curie highlighted, staff safety and wellbeing contribute to a safe and high-quality care. Such a bill will require to be underpinned by the appropriate technology. In taking the evidence in the committee, this was a thread that I was keen to pursue. My concern in that regard is that a replacement platform developed specifically to deliver on the objectives of the bill has not been addressed prior to the introduction of the bill. However, developing appropriate technology is fundamental to the success of the bill's objectives. We were surprised that setting up a review of the current tools had not been undertaken prior to the introduction of the bill to assess the efficacy of the tools. The starting point of any bill should be the consideration of the end objectives. Let us face it. The Government has not exactly been particularly successful in rolling out technology. To be successful in developing technology, fully scoping the project with tight protocols is essential. To me, understanding this step should have been a prerequisite prior to the bill's introduction. We also have the situation where the implementation of current tools is patchy at best. I always enjoy listening to Alex Neil's contributions in the debates. Alex Neil is absolutely right that we have wonderful technology companies in Scotland that are currently developing some fantastic products. Where we fall down is integrating that into the health service. We are not particularly good at that. The use of those tools and the integration of those tools has to be considered. As it currently stands, the technology that the Government is relying on is for nurse and magnifory workforce tools. They are bolted on to an existing platform, and that is a recipe for confusion. We do not seem to deliver that patient medical practitioner outcome focus. As Miles Briggs spoke about his speech, we need to be looking at outcomes versus process. I think that COSLA mentioned themselves and I quoted that they see the bill as focusing on inputs rather than outcomes. Indeed, the committee noted that the Scottish Government does not view outcomes that are needed to be on the bill. If outcomes were primary objectives, we would have allied healthcare professionals and occupational therapists, social care, all intrinsically woven into the software development before ever launching, because an outcome focus solution must involve that multidisciplinary team. It is inconceivable that any healthcare plan could be effective without our physiotherapists, our radiographers, our speech therapists, our mental health practitioners, social care healthcare professionals and so on. It is very welcome to hear the cabinet secretary suggesting that stage 2 amendments will be put forward to address this, and we look forward to seeing and assessing those amendments. I was pleased to hear that NSS are undertaking work to procure a new platform to replace the SSTS platform, but that is being done without the development plan for the workforce planning tools that are required for that multidisciplinary team approach. There is a need for that work to be done in conjunction with the introduction of the bill if patient and staff outcomes, rather than process, are to be the main drivers. Of course, the danger and unintended consequences of tools applying only to nurses and midwife have been highlighted by many across the chamber and that they may squeeze out those other disciplines, such as the allied healthcare professionals, occupational therapists, social care and so on. Rani Wells highlighted the concerns of the third sector, and given that a third of the volunteer sector is already involved in social care, it needs to be persuaded. I know that the SCVO suggested that there was no particular benefit coming from the bill. It is also noting that the law society mentioned that it is difficult to assess from the face of the bill whether the main policy objective of appropriate staffing will be met as the bill is largely a vehicle for more legislation to come. The Charter Society of Physiotherapy warned that it is a danger that individuals are held accountable for not being able to provide safe levels despite circumstances being out of their control. Other sectors, such as the care sector, have raised similar concerns. Unison Scotland noted that if the Scottish Government decided to proceed with the bill in a fashion that requires adherence, the Scottish Government need to make clear who is responsible for delivering that policy. If the bill cannot clarify specific lines of accountability, in some ways, the bill will become redundant. If the Charter Society of Social Care and the introduction of commissioners into the process without them being referenced in the bill, how are they required to adhere to the guiding principles? I am sure that all members across the chamber would agree that the Scottish Government's objectives are not only laudable but essential. However, if the bill is to succeed, I think that it is true that there is work to do. In supporting this bill at this stage, we recognise that the elephant in the room is, of course, the shortage of staff across all medical professionals. Unless we address that, the potential of the bill will be eroded. I call Jeane Freeman to close the debate. We have a little extra time, so a generous 10 minutes should take us to decision time, please, cabinet secretary. I, along with others, believe that this has indeed been a good debate, which has encapsulated the complexity of the legislation and the importance of making sure that it acts as an enabler for the development of more evidence-based, profession-led methods of assessing the workload associated with the delivery of care for the people of Scotland. I want to thank all members who have taken part in the debate and also take this opportunity to thank the Delegated Powers and Law Reform Committee, the Finance Committee and, of course, in particular, the Health and Sport Committee again for their work to inform Parliament's consideration of the bill. I also want to take this opportunity before I turn to specific points that members have raised to thank our key partners across the health and care sector for their constructive engagement with us and for the considerable input to the bill so far. I have listened very carefully to all the views that have been expressed. I will return to this later on before I conclude and will continue to work with them to ensure that the bill delivers what we want to deliver. Let me turn, if I may, to some of the points that have been made. Even with the generous 10 minutes, I am not going to be able to cover them all, but let me say this before I start. What we will absolutely do after this debate has concluded, and I hope that Parliament supports stage 1 of this bill, is that we will then look very carefully at the record of this debate to make sure that all the points that have been raised are then carefully considered by me on what we might do and will be dealt with when I come to the Health and Sport Committee to give evidence at stage 2. In terms of the stage 2 amendments, I am absolutely certain that members across this chamber will want to bring forward amendments. As was my approach in social security, I want to offer the opportunity to discuss those stage 2 amendments before they are finally lodged in order that we can be sure that we can reach agreement that we do that in advance. I would hate us to be in a position where the Government agrees with the principle and the spirit of an amendment but cannot agree with it simply because some of the words are not quite right in legislative terms. We managed that before I am certain that we can manage it again. I am not seeking to subsume everyone's amendments as Government amendments, but I am seeking very clearly to work as hard as I can to reach consensus across this piece of legislation because I believe that it is a piece of legislation whose principles we are all agreed on, whose importance we are all recognised and what we all want to do is make good law that will aid us in the work that we have at hand. I turn particularly to some of the points that Lewis MacDonald made in speaking on behalf of the committee. I am grateful for the very considered report that the committee has brought to our considerations and to the contribution that he made. I take the point about the bill being to process focus at the expense of outcomes. I know that others have made it and, indeed, COSLA has raised it as a concern. I do not believe that that to be the case. I do believe that the outcome focus of the point of the bill is recognised in it and is perfectly willing to look at whether we can strengthen that to make that even clearer. However, I cannot understand the thinking that it says that if we have evidence-based robust approach and a clear methodology consistently applied across our health and social care sector, appropriate to those settings that allow us to identify workload that then allows professional judgment to be exercised to identify what staff are needed and skill mix is needed, that surely goes to the provision of high-quality outcomes for patients and staff. If that is not clear enough, as I said, I am very happy to look at that in some more detail. I am grateful to Mr MacDonald for recognising the importance of rolling out excellence in care and raising the point of monitoring and compliance. I think that Anasawa made some useful points in his contribution about how the public and, indeed, this chamber, as the bill is passed into legislation—which, obviously, I hope it is—and is enacted in the way in which people can be advised of the work that is going on and the results that are being produced and compare and contrast that to the work that goes on in terms of workforce planning, recruiting and training appropriate levels of staff across all those areas. I am happy, as I said, to look at how we might strengthen that in the bill. I do not believe that the bill will skew resources from one set of tools because one set of tools is ahead of the other. I think that we have been very clear that, as the tools are developed appropriate to individual settings—in which we would look to see them put in place—we will be working with the appropriate stakeholders to make sure that that is appropriate for those community-based settings, although it is currently the case that the existing tools cover both acute and community. However, I would take Alex Neil's point very strongly that, when we talk about community setting, we are not only talking about social care, but about the primary care setting as well. One of the questions that was raised, Jess. Annas Sarwar I thank the cabinet secretary for taking an intervention. I realise that she cannot go through all the requests that were made, but can she specifically respond to the point around looking at a cap on agency fees and charges? Jeane Freeman I am getting there, Mr Sarwar. On the question about how does that differ from the current mandate, why do we need legislation as opposed to the current mandate? Let me just say that one of those who contributed—actually, I think that it was Mr Stewart—made it very clear why we need to move from a mandate to legislation. We have the mandate, but we do not have sufficient training, we do not have time for training, we do not have support for staff, we do not have support to ensure that the information that is produced is analysed and then applied. The legislation will allow us to do that. In terms of who is accountable, for healthcare, the bill, if passed, will add to the 1978 National Health Service Scotland act, which then makes that a duty for the health board to be accountable. That health board includes the chief officers of IJBs, and for the care inspectorate, similarly, their existing powers would apply. The issue of accountability can be answered, although I am happy to discuss that further. Let me turn to the point before we run out of time about a cap on what agency charges are. I agree with Mr Sarwar in full that the current situation that he gave examples of is unacceptable. I am not certain that we have the powers as a Government to do what he asks in terms of capping it, but I am very happy to continue to discuss that further with him and his colleagues to see what more we might do. The application of the legislation should lead to a continued reduction in agency requirement and agency spend. I would make the point that it is in the current year down 7 per cent from what it was previously, but the application of the legislation should allow us to drive that down even further. However, I am happy to look at that. Can I take the opportunity to thank Mr Sarwar for his contribution for being able to say that here are the things that we think are wrong with the legislation so far, how it could be strengthened and then offering very concrete suggestions for it. I need to make the point about Brexit. I am not standing here and saying that our current issues around recruitment and retention are exclusively down to Brexit, but Brexit will exacerbate the problem that we have. There is no question of that, but so too will immigration legislation that does not meet the particular needs of Scotland and the Scottish economy and the Scottish population. That is why the whole area of immigration powers are ones that need to be seriously considered about coming to this Parliament and not simply residing in Westminster where they are skewed. Yes, of course. David Stewart The cabinet secretary will be well aware of the UK Government changes, I think, just this week, which has doubled the non-EU NHS levy that has to be paid to staff, which will affect a health service in Scotland. Has the cabinet secretary been in the assessment of the effect that is going on? Cabinet secretary? Well, I cannot think that it will be a good one, but I have not made it yet in detail. I am happy when we have done that to let Mr Stewart know how that might add to the difficulties that we are facing. The final point that I want to make, Presiding Officer, is in terms of what Mr Mountain and others said about looking at wellbeing in terms of this particular piece of legislation. Again, I am very happy to look at an amendment that might strengthen that area and to discuss that further. We need to be careful that we do not stray into health and safety or employment legislation, because that is, of course, reserved. We could not do that, but I am very happy to look at that. My last point before I conclude, Presiding Officer, is to say that I really do not think that it is either or in terms of assessing workload and workforce planning. We should not wait for one to be got right before we do the other. The two need to go hand in hand, but I believe that that bill will further strengthen, at stage 2, undoubtedly, significantly contribute to our capacity to increase the performance of our workforce planning, its efficacy and, from that, the numbers that we support and require in training across a whole range of professions. Finally, Presiding Officer, I am, as I always am, very open to further conversations as we go into stage 2 to look to see how far we can reach consensus on this important piece of legislation. There will undoubtedly be areas where we disagree, but I am certain that, with good will from across this chamber, we can get a piece of legislation that is not only fit for purpose but fit for the needs and expectations of the people that we serve. Thank you very much. That concludes our debate on the health and care staffing Scotland bill. The next item of business is consideration of motion 14969 on the financial resolution for the health and care staffing Scotland bill. The next item is consideration of business motion 15076, in the name of Graeme Dey, on behalf of the Parliamentary Bureau, setting out a revised business programme. I call Graeme Dey to move the motion. Thank you very much. No member seems to wish to speak against the motion. Therefore, the question is that motion 15076 be agreed. Are we all agreed? We are, thank you. And we turn now to decision time. There are two questions today. The first question is that motion 15055, in the name of Jeane Freeman, on stage 1 of the health and care staffing Scotland will be agreed. Are we all agreed? We are agreed. And the final question is that motion 14969, in the name of Derek Mackay, on a financial resolution for the health and care staffing Scotland will be agreed. Are we all agreed? We are agreed and that concludes the decision time. I close this meeting.