 Welcome to the third meeting of the Health and Sport Committee in 2019. Can I ask everyone in the room please to ensure that mobile phones are switched off or on silent? While it is acceptable to use mobile devices for social media within the room, please do not take photographs or record proceedings. The first item on the agenda is consideration of a negative instrument, the foods for specific groups, medical foods, miscellaneous amendments, Scotland regulations 2018. There has been no notice to annul this instrument, the Delegated Powers and Law Reform Committee considered the instrument at its meeting on 22 January and agreed to draw the regulations to the attention of Parliament on the general reporting ground as the preamble to the instrument does not follow proper drafting practice. At the same time they did not feel that the inadequacies were such as to justify asking for the instrument to be redrafted. Can I invite any members who have any comments to make on this instrument? If not, is the committee agreed to make no recommendations in relation to this instrument? Thank you very much. The second item on the agenda is stage 2 consideration of the health and care staffing Scotland Bill. I welcome the cabinet secretary, Jeane Freeman, who is accompanied by Diane Murray, associate chief nursing officer, Louise Cable, team leader, Julie Davidson and Joanna Irvin from the legal directorate and Jonathan Brown Parliamentary Council. Their presence at the table will vary according to which items are being debated. I also welcome Monica Lennon and back Alison Johnson, who are here with amendments for this bill and welcome in advance Anas Sarwar, who will be joining us for the same reason. Members should have with them a copy of the bill as introduced. The marshal list of amendments that was published on Thursday and the groupings of amendments would set out amendments in the order in which they will be debated. It may be helpful to members and others if I explain briefly the procedure. There will be one debate on each group of amendments. I will call the member who lodged the first amendment in each group to speak to and move that amendment and to speak to all the other amendments in the group. I will then call any other members who have lodged amendments in the same group. Members who have not lodged amendments in a group but who wish to speak should indicate that by catching my attention in the usual way. I will invite the cabinet secretary to contribute to the debate just before winding up if she has not already moved an amendment in that group. I will then conclude the debate on that group by inviting the initial mover of the first amendment to wind up. Following the debate on each group, I will ask the member who moved the first amendment if he or she wishes to press it to a vote or to withdraw. If the member wishes to press the amendment, it will be put. If a member wishes to withdraw an amendment after it has been moved, that must have the agreement of other members of the committee. If any member objects to the withdrawal of an amendment, the committee will move to a vote on it. If any member does not want to move an amendment which has been called, simply say not moved when I ask and please note that any other member present may move such an amendment. If no one moves an amendment such an amendment, I will move immediately on to the next one. Only members of the committee will vote on the amendments. Voting in any division is by show of hands and I remind members to indicate their intention clearly and to keep their hands in a position where they can be seen and their votes recorded fully by members of the clerking team. I will also ask for the committee to approve each section of the bill as we reach the end of that section. I will put a question on that section at the appropriate point. We will make what progress we can today and seek to get through as much of stage 2 as we can by 12 o'clock, so we can now move straight on. I will start with section 1, guiding principles for health and care staffing, and I would call amendment 81 in the name of Monica Lennon, a group with the amendments that are shown in that group, to move amendment 81 and speak to all amendments in the group. Monica Lennon. Good morning, convener and member of the committee, cabinet secretary. I will start to just crack on then. Amendments 81 and 82, alongside amendment 83, have the effect of ensuring that the purpose of staffing definition includes a reference that should achieve the best possible outcomes for patients. Those three amendments taken together ensure that individuals, be they NHS patients or people using social care services, are placed at the heart of what this bill is trying to achieve. I am sure that we all agree that staff are the backbone of the NHS, but they are not there purely to deliver a service for the sake of it. They are there to look after and care for patients and users of those services. That is also reflected in amendment 1 in Alex Cole-Hamilton's name. However, the health and social care sector operates with this mindset and the policy memorandum for this bill itself states that the aim of this bill is to be an enabler of high-quality care and improved outcome for service users. If that is to be the intention, I believe that it should be explicit on the face of the bill, especially as it is through the lens of the guiding principles that the rest of the duties in the bill are to be interpreted and implemented. Otherwise, the bill could run the risk of becoming process-driven and just setting a new tick box exercise, which no one around the table wants. Amendment 8, in the name of the cabinet secretary, Jeane Freeman, adds some proving outcomes to a list of considerations to be factored in while arranging health and social care staffing. However, in the bill, this section as caveated has only been required as far as consistent with the main purpose. Ensuring the best outcomes for patients, nor is requiring social care, should not be caveated, in my opinion. It is the reason why we have health and care services and staff in the first place. Those are my remarks in terms of the amendments in this group so far. I ask Alex Cole-Hamilton to speak to amendment 1 and other amendments in the group. Thank you, convener. I move the amendments in my name. They should not be controversial amendments. Monica Lennon has already alluded to the reasoning behind them. That is to recognise that person-centred planning is absolutely key throughout the whole of our health and care services. However, the bill does not necessarily reflect that in its language, as it currently stands. My amendments 1 and 2 in my name seek to extend the reach of this to recognise that this has to be about the health, safety and wellbeing of service users, as much as it is about staff. To that end, the only other amendment that I have a problem with in this section is amendment 9, in the name of the cabinet secretary. Only because I believe that it dilutes the intent of the bill, which went as originally drafted from being right staff, right place, right time, to make better use of the available staff and resources at the time. I think that we need to throw our cap over the wall on this and be a bit stronger about our intent. Amendment 11 in my name is really important in terms of the debate that we heard throughout stage 1 about extending the reach of this bill to allied health care professionals and recognising that the toolkit and the tools that are contained within it have application far beyond primary care clinicians. We have heard very strong testimony from a range of allied health care professionals about their desire to be included in the bill, that they want to work towards this as best practice as well, and indeed to work together with primary care colleagues. I think that there was some confusion or some anxiety from the RTN about the use of the term together, but they are quite happy with it so long as the intent behind it, and I can confirm the intent behind it, is about a collaborative approach rather than necessarily working side by side or cheap by gel. As such, I am happy to move the amendments in my name. Thank you very much. I can ask the cabinet secretary to speak to amendment 8 and other amendments in the group. Thank you, convener, and good morning to you and all present. In its stage 1 report, the committee asked the Scottish Government to place on the face of the bill an additional guiding principle linking the outcome focus to the health and care standard and quality measures. Amendments 8 and 12, which insert a new general principle of improving standards and outcomes for service users, alongside a definition that provides that by standards and outcomes for service users we mean the health and social care standards are intended to do just that. Amendment 9 removes allocating staff efficiently effectively from the list of guiding principles in section 1, subsection 1b, and replaces it with making the best use of the available individuals, facilities and resources. This same wording was used in the Public Body's Joint Working Scotland Act 2014, integration planning principles, and in my view makes it clear that we do not simply wish to see health boards and care services address each and every risk by bringing in agency staff. We wish to see them managing their services and staff effectively and efficiently, and also to considering whole service redesign where appropriate to ensure that they are providing the best service possible to their patients and service users. I heard the concern from some staff groups that the bill was not specific enough about their inclusion and did not recognise the importance of multidisciplinary working. Amendment 10 will make it clear in the guiding principles that multidisciplinary approaches to staffing should be promoted where appropriate. I can confirm that the Government is happy to support Alex Cole-Hamilton's amendment 11, with its definition of a multidisciplinary service in section 1 of the bill. Amendment 14, relatedly, provides further clarification in the general duty in section 121A to ensure appropriate staffing that the contribution of all professional disciplines to delivery of high quality care must be considered. I now come to amendments 1 and 2 from Mr Cole-Hamilton. While I am supportive of those amendments, they are with respect, in my opinion, entirely unnecessary and steamed to have stemmed from a slight misunderstanding of the legislation as it is currently drafted. The duty to ensure appropriate staffing in section 121A already sets out that for the NHS. It is the duty of every health board and the agency to ensure that, at all times, suitably qualified and competent individuals are working in such numbers, as are appropriate for the health, wellbeing and safety of patients, and the provision of high-quality healthcare. There is an equivalent duty for any person who provides a care service in part 3 of the bill. Sections 2 and 3 of the bill set out that every health board in complying with section 12IE and any person, my apologies, who provides a care service in complying with section 6 of the bill must have regard to the guiding principles. As such, the principles and the general duty are intrinsically linked. Those who must follow the general duty must have regard to the guiding principles in doing so. Amendments 1 and 2 are therefore not necessary, in my opinion, as they add nothing new to the bill but instead duplicate and, through amendment 2, arguably triplicate something that is clearly set out in the bill. If I can explain a bit more taking literally, that would mean that a health board would be legally required to provide appropriate numbers of staff for the health, wellbeing and safety of patients, and in doing so would have to arrange staffing for the health, wellbeing and safety of patients, and in so far as consistent for that purpose, they would have to arrange staffing for the health, wellbeing and safety of patients. I am sure that the committee gets my point. I would say to Mr Cole-Hamilton that we do not need to triplicate the statutory duties for them to have legal force, and on that basis I ask the committee not to support amendments 1 and 2. Finally, convener, in relation to amendments 81, 82 and 83 from Ms Lennon, the guiding principles in section 1 apply across health and social care and must recognise that the positive outcomes service users wish to see are not just clinical or medical in nature. Amendment 83 would state that the purpose of staffing for health and care services is to ensure the best health outcomes and neglects to mention the wider care outcomes. Those wider health and care outcomes are set out in the health and social care standards, and for that reason I would ask the committee to reject amendments 81 to 83, and I move the amendments in my name. Thank you very much. If there are no other members who are supposed to speak, can I ask Monica Lennon to wind up, please? Thank you, convener. I think that the cabinet secretary has made some both valid and some interesting points, but I am sure that members will have put a lot of work into their own amendments and that there might be some point to disagree on here. I really do not get anything more to add, just in terms of—excuse me—one second. I am supportive of the amendments—I do not know if I have a vote in this committee. The one that I did have concerns around was amendment 9, because I know that the RCN has expressed some concerns, but I think that the cabinet secretary at this point has taken a different view, so generally supportive, but I have some issues with amendment 9, but I move the amendments in my name. Thank you very much. Amendment 81, do you wish to press or withdraw? Thank you very much. The question is that amendment 81 be agreed to, or are we all agreed? In that case, we shall take a vote. Can I see those in favour of amendment 81? Thank you very much, and those against. That amendment is carried. Can I call amendment— sorry, my apologies—I should announce the result of that vote, which is 5 in favour and 4 against, and that amendment is therefore carried. Can I call amendment 82, in the name of Monica Lennon, already debated with amendment 81? Monica Lennon, to move or not? Moved. Are we all—the question is that amendment 82 be agreed to, or are we all agreed? Again, a vote on amendment 82, can I see all those in favour of amendment 82? And all those against. The result of the vote on that amendment is 5 in favour and 4 against. Amendment 82 is therefore agreed. Can I call amendment 1, in the name of Alex Cole-Hamilton, already debated with amendment 81? Alex Cole-Hamilton, to move or not move. Are we all in favour of amendment 1? In that case, a vote again. Can we see all those in favour of amendment 1? And all those against. The result of that vote is 5 in favour and 4 against. Amendment 1 is therefore carried. Can I call amendment 83, in the name of Monica Lennon, already debated with amendment 81? Monica Lennon, to move or not move. The question is that amendment 83 be agreed to, or are we all agreed? Can we vote those in favour, please, of amendment 83? And those against. The result of that vote is 5 in favour and 4 against. Can I call amendment 82, in the name of Alex Cole-Hamilton, already debated with amendment 81? Alex Cole-Hamilton, to move or not move. Are we all in favour of amendment 2? Can we therefore see a vote, please, for those in favour of amendment 2? And those against. The result of that division is 5 in favour and 4 against. Amendment 2 is therefore carried. Can I call amendment 8, in the name of the cabinet secretary, already debated with amendment 81? Cabinet secretary, to move. Thank you very much. The question is that amendment 8 be agreed to, or are we all agreed? Yes. We are all agreed. Can I call amendment 9, in the name of the cabinet secretary, already debated with amendment 81? Cabinet secretary, moved. Question is that amendment 9 be agreed to, are we all agreed? We are not agreed, can I see those in favour of amendment 9 and those against? If the vote in that case was 4 in favour and 5 against, amendment 9 is not agreed. Can I call amendment 10, in the name of the cabinet secretary, already debated with amendment 81? Cabinet secretary, moved. Thank you very much. Question is that amendment 10 be agreed to, or are we all agreed? Yes. Can I call amendment 11, in the name of Alex Cole-Hamilton, already debated with amendment 81? Alex Cole-Hamilton, to move or not to move? Moved. Moved. Are we all in favour of amendment 11, in the name of Alex Cole-Hamilton? Yes. Are we all agreed? Call amendment 12, in the name of the cabinet secretary, already debated with amendment 81? Cabinet secretary, to move. Moved. Thank you very much. Question is that amendment 12 be agreed to, are we all agreed? Yes. Thank you very much. The question then is that section 1 be agreed to, are we all agreed? Yes. Thank you very much. Move on to section 2, duties on commissioners of health and care. Can I start, please, by calling amendment 84, in the name of Miles Briggs, grouped with other amendments within the group? Miles Briggs, to move amendment 84 and speak to all amendments in the group. Thank you, convener, and good morning to everybody. Amendment 84, the purpose of the amendment is to place a duty on commissioners to be satisfied that, in contracting or agreeing services, they have taken into account all reasonable steps to ensure that providers are able to deliver health services, which have appropriate staffing arrangements. As drafted, commissioners must not only have regard to the guiding principles and the need to have appropriate staffing arrangements in place. Commissioners should be clear of their part in ensuring staffing for safe and effective care. As commissioners NHS boards and integration authorities should therefore be under a clear duty to commission services in a way that allow health service providers to arrange staffing for safe, high-quality care. If services are not commissioned with, for example, sufficient funding to ensure appropriate numbers of staff or staff with appropriate expertise, it is the provider and not the commissioner who will be held accountable. Ultimately, it is patients who may experience poor quality care as a result. My amendment 86 is similar and replicates this for care services, and I move both amendments in my name. Thank you very much. I call Monica Lennon to speak to amendment 85 and other amendments in the group. Monica Lennon Thank you, convener. The amendments 85, 87 and 89 are aimed at improving the ease of which there can be scrutiny of staffing levels and the implementation of the duties contained within this bill. For health services, amendment 85, in my name, does this by, firstly, improving the information that is made available about decisions concerning staffing levels within our health services. Secondly, ensuring that decisions about staffing levels are linked to improving outcomes for service users rather than for financial or practical reasons. Requiring Scottish ministers to make this information public by reporting to Parliament and finally requiring Scottish ministers to respond to decisions that have been taken by health service providers with regard to staffing, setting out what action they intend to take with regard to staffing in the health services. The intention of this final obligation on Scottish ministers is to connect this bill, which is very process driven and focused on on the ground work load planning, to national level workforce planning. Decisions that are made at a national government level have an impact on the ability of health and care providers to provide staff for services, be that because of the budget choices that are made, the number of training places that are made available or the registration and recruitment process that are required and so on. I note that amendment 90, in the name of Alison Johnstone, although not in this group, is complementary to this, as it plays a duty on ministers to ensure adequate supply of health care staff. Amendment 85, in my name, is intended to provide full scrutiny of the decisions that have been made up the chain of accountability. Amendment 87 is a small amendment that ensures that commissioners must consider all the obligations on providers as opposed to just those listed later in the bill. Amendment 89 is very similar to the amendment 85, in that it adds the same obligations of reporting on commissioners of care as amendment 85 does to healthcare providers. Similar to amendment 85, it is aimed at improving scrutiny of the implementation of the bill and staffing levels in the social care sector. Should the amendments in the name of Miles Briggs and David Stewart pass, it will also require commissioners to report when financial decisions have been made about staffing levels and the available resources for staffing in the commissioning of care services. As with amendment 85, amendment 89 also scrutinises the decisions made by ministers and requires them to respond to the situations faced by the sector. A slight difference between amendment 85 and 89 is that amendment 89 requires reporting on the risk faced by commissioners of care in complying with the duty. I believe that it is important that that is included so that the context in which decisions are taken are made clear. For example, the financial context, as many social care budgets are squeezed, however, could also relate to a lack of available staff. Although a reference to risk is not included in amendment 85, it has not been totally left out. Instead, it has been added to an amendment in a different group that references the content of health board reports to a Scottish minister on staffing and seems more appropriate to place it there. Thank you very much, and I call David Stewart to speak to amendment 88 and other amendments. Thank you, convener, and welcome to everyone today. I will speak to and move two amendments in my name, that is amendment 88 and 110, which seeks to ensure that commissioners of care services bear a similar responsibility and duty with regard to the staffing of care services as it is given to care providers. In evidence at stage 1, the committee heard from groups within the social care sector who were concerned that the bill placed all the focus on care providers and did not adequately recognise the impact that commission decisions about funding and resources have on staffing levels. I recognise amendment 86, in the name of Miles Briggs, seeks to ensure that sufficient funding is to be given to providers to provide adequate staffing arrangements. I believe that amendment 110, in my name, is complementary to that. The reference resources would include funding, but by mirroring the wording of the existing section 6, my amendment would specifically require commissioners to take into consideration all the same factors as those required of service providers when determining the appropriate staffing levels. Locating this new duty in commissioners ahead of the existing duty in section 6 also indicates the sheer responsibility between commissioners and providers to provide adequate staffing and the lines in the latter on the form when it comes to the ability to comply with the duty. I acknowledge the note that was given to the committee yesterday from Scottish Care referencing amendment 110 and the concern that would limit the ability for providers to embrace new technologies. However, I respectfully suggest that the additional considerations in Subsection 2, my amendment, specifically 2E, and the reference to the needs of service users provide flexibility in how the required number of staff is assessed. Similar wording is used in section 4 with regard to healthcare services. I am aware that the social care sector differs from the health sector, however, new technologies have adapted how we provide services within the healthcare system. Subsequent to the staff and professions that are needed to provide these services, there is no reason why some of the situation and principles should not apply to social care. Amendment 88, in my name, is a consequential amendment 110, and it requires the additional duty of commissioners to be considered by then. Should amendment 89, in the name of my colleague Monica Lennon, be passed, it also closes the feedback loop and ensures that any reporting to the Scottish ministers includes reference to the additional duty on commissioners. Amendment 84 and 86, lodged by Mr Briggs, are parallel provisions that apply respectively to healthcare planning and care service planning. I therefore intend to speak to both before addressing the rest of the amendments in the group. I am, in truth, not clear what could be achieved by amendment 84 and what its aim is. It would require health boards to take all reasonable steps to provide sufficient funds to persons from whom they have contracted a service or entered into an arrangement under the 1978 NHS act. It amends section 2 of the bill, but section 2 does not apply to commissioning of services by the integration authority. It applies to the contracting of services from a private healthcare provider or agency staff. Agreement on the payment required for the provision of a service is an integral part of the contracting process. More importantly, in contracting a service by virtue of the National Health Service Scotland act 1978, a health board retains accountability for the services provided under that contract and must ensure that they are delivered in an appropriate way. Put simply, a service provider would not agree to the contract if the amount set out in it was insufficient, and a board would not agree to a contract if it had not satisfied itself that the provider would deliver the required quality of care and level of staffing. Amendment 86 would amend section 3 to place a similar duty on local authorities and integration authorities to provide sufficient funds to those from whom they contract a care service. Section 3 applies to the contracting of a service from a care service provider by a local authority or integration authority. It may be that Mr Briggs has brought those amendments forward due to a concern that local authorities are contracting services from care service providers, as planned by the integration authority, in cases where the amount pays does not allow a care service provider to have appropriate staff in place. As with contracting of services in health, where a care service provider tenders for a contract with a local authority, both must agree that the amount paid for that service allows them to comply with their respective duties before agreeing to the contract. Section 3 requires local authorities and integration authorities to have regard to the duties placed on care service providers. As drafted, those amendments do not work because it is not the responsibility of the health board or local authority to provide funds, they pay for a service and are accountable for ensuring that that service meets the legislative requirements. If Mr Briggs has remaining concerns, I would suggest that we work together to fully understand what those are and look to draft an amendment for stage 3 that he can return with at that point. I would ask Mr Briggs not to press amendments 84 and 86 on the understanding that I will work with him to address his concerns and bring forward an amendment at stage 3 if he wishes. Amendment 85 would require health boards to report on how they have complied with the duties placed on them under section 2. That is something that could be included in the existing reporting duty set out at 12ie and I would be happy to make that more explicit at stage 3. I would ask the committee to reject amendment 85 on the basis that I will amend section 12ie at stage 3. Amendment 87 would create a circular reference. Section 31 imposes a duty to have regard to the guiding principles when carrying out the section 6 duty. Section 32 is then about the planning aspect and when arrangements are being secured to get the care service delivered operationally by another person. The guiding principles already apply under section 32a. Since commissioners already have to have regard to them under that provision, to create a duty to have regard to the duty to have regard to them is entirely circular. On that basis, I ask the committee to reject amendment 87. Amendment 89 would require local authorities and integration authorities to report on their compliance with section 3 brackets 2 and any risk that may affect their ability to comply. There are existing statutory requirements on integration authorities to plan for the use of their resources in the context of their available budgets, publish those services and financial plans annually and report on them annually. The amendment therefore creates duplication within existing statutory duties and for that reason I would ask the committee to reject it. I have serious concerns about the impact amendments 88 and 110 would have on the success of integration. Integration authorities are already under a statutory obligation to deliver best value in terms of the quality of care that they commission within the resources that are available to them. By bringing together expertise in health and social care services, integration authorities are developing innovative approaches to care that focus on prevention, support and independence for people with multiple complex needs for whom community-based support can often provide a better outcome than would be found in a hospital or care home. Amendment 110, by focusing on an obligation to provide a defined amount of money for a defined service for a particular period of time, risks inhibiting local partner's capacity for flexibility and innovation within their total available resources. The amendment also focuses only on social care and does not apply to health. I assume that amendment has been brought forward due to some concerns about adequate funding for care service providers, so I extend to Mr Stewart the same offer that I made to Mr Briggs to work together on drafting something that will work for stage 3 and for that reason I would ask Mr Stewart not to press amendments 88 and 110. Thank you very much, cabinet secretary. Can I ask Miles Briggs to wind up and to press a withdrawal amendment 84? My amendments look to place a duty on commissioners to be satisfied. I think that that is key that, in contracting or agreeing services, they have taken into account all reasonable steps to ensure that providers are able to deliver health services with appropriate staffing arrangements. Given what the cabinet secretary has said, I welcome the constructive aspect of that, and if Dave is also agreed, I am happy not to press my two amendments at this stage. Thank you very much. That is amendment 84 in the first instance, and I was the committee content that that has been not pressed. Thank you very much. Can I therefore call amendment 85 in the name of Monica Lennon, already debated with amendment 84? Monica Lennon to move or not move? I will move today, convener. I did not quite catch everything that the cabinet secretary said, but I think that there was a welcome commitment there to amend 12. I am not sure if that captured everything that I was looking to do, but I would be happy to discuss that with the cabinet secretary, but I will press today as a safeguard. Thank you very much. The question is that amendment 85 be agreed to. Are we all agreed? Okay. Can I see those in favour of amendment 85 in the name of Monica Lennon and those against? Amendment 85 is carried by five votes to four. The question is that section two be agreed to. Are we all agreed? Section two. Are we all agreed to section two? Thank you very much. Can I now call amendment 86 in the name of Miles Briggs, already debated with amendment 84? Miles Briggs to move or not move? Not moved. Thank you very much. Can I now call amendment 87 in the name of Monica Lennon, already debated with amendment 84? Monica Lennon to move or not? Moved. Moved. The question is that amendment 87 be agreed to. Are we all agreed? Can I see those in favour of amendment 87 and those against? Thank you very much. The vote is five-four in favour of amendment 87, which is passed. Can I call amendment 88 in the name of David Stewart, already debated with amendment 84? David Stewart to move or not move? In light of the cabinet secretary's comments, I am not going to move that amendment. Thank you very much. We move on then to the section on ministerial guidance on staffing by care services. Can I call amendment 13 in the name of the cabinet secretary? Cabinet secretary, to move amendment 13 and speak to all amendments in the group. Convener, amendments 13, 68, 69, 70 and 71 relate to the guidance on staffing by care services that ministers can produce under the bill. Amendment 13 would allow ministers to issue guidance about the duty of commissioners of care services under section 3 brackets 2 of the bill to have regard when commissioning services to the guiding principles for care staffing and to certain statutory duties relating to staffing on care service providers. As with the other guidance powers in the bill, this would be subject to consultation and would have to be published. Section 8 brackets 1 of the bill already sets out that guidance can cover the duties placed on care service providers under section 6 and section 7 on ensuring appropriate staffing and adequate training of staff respectively. Amendment 68 clarifies that the guidance can also cover the guiding principles. Section 8 brackets 2 lists those with whom ministers must consult before issuing the guidance. Amendment 69 adds the Scottish Social Services Council to the list. The SSSC highlighted its omission from the list when giving evidence to the committee. As the regulator for the social service workforce in Scotland, I agree that it is essential that their views are sought and that it had been my intention to consult with SSSC through section 8.2D, which allows ministers to consult with such other persons as they consider appropriate. I am therefore happy to bring forward this amendment and to provide assurance to SSSC that it will be consulted. Amendment 70 adds those who commission services to the list of those with whom ministers must consult before issuing the guidance. That will include integration authorities whose addition was suggested in some of the written evidence submitted to the committee. I have listened to the views expressed to the committee by third sector bodies who wanted a stronger commitment in the bill to seek the views of service users, their carers and third sector organisations who represent them. Section 82B already requires ministers to consult with representatives of service users. Amendment 71 adds representatives of carers to the list with whom ministers must consult before issuing guidance under section 8 to care service providers. I move amendment 13 and the others in the group in my name. Thank you very much, cabinet secretary. Can I ask if any members of the committee wish to again a contribution on amendments in this group? If not, Sandra White. Thank you very much. One of the issues that I not necessarily wanted to raise but to mention again that, obviously, this bill is inclusive in regard to nursing and social care as well. I think that amendment goes some way to explaining that and putting that across, which is not just about acute care primary but about social care as well. I welcome the addition from the cabinet secretary. Thank you very much. If there are no other contributions, can I ask the cabinet secretary if she wishes to wind up? I just want to make one final point, convener. That is to welcome what Ms White has said. I think that it is a very important point for us to be reminded of at this stage in our deliberations. This bill is intended to uncover both health and social care. Therefore, we need to be very careful not to over-medicalise social care and not to ignore social care and the views of those operating and delivering in that area of service. It is entirely compliant with our overall cross-party support for the integration of health and social care. I am grateful to Ms White for making that point. Other than that, I have nothing more to say. The question then is that amendment 13 be agreed to. Are we all agreed? Thank you very much. Can I call amendment 89 in the name of Monica Lennon, already debated with amendment 84, Monica Lennon to move or not move? Thank you very much. The question is that amendment 89 be agreed. Are we all agreed? We are not all agreed. Therefore, can I see votes please in favour of amendment 89 in the name of Monica Lennon and votes against? That amendment is carried by a vote of 5 to 4 and amendment 89 is therefore agreed. The question is that section 3 of the bill be agreed. Are we all agreed? Thank you very much. Moving on to section 4. Can I call amendment 14 in the name of the cabinet secretary, already debated with amendment 81? Cabinet secretary, to move firmly. The question is that amendment 14 be agreed to. Are we all agreed? Yes. Thank you very much. Move on to the next group, which is in relation to the duty to ensure appropriate staffing, purposes of staffing. Can I call amendment 3 in the name of Alex Cole-Hamilton group with amendments 4, 5, 15 and 16? Alex Cole-Hamilton to move amendment 3 and speak to all amendments in the group. Thank you again, convener. Again, I hope that those will not prove a controversial set of amendments. It is about extending the reach of this bill and recognising that, whilst absolutely patient safety has to be paramount, so too does that of staff. I used in stage 1 an example that I had been told to me by a stakeholder of a psychiatric unit where their union phoned to ask professionals whether they had a safe staffing compliment that night. They said, well, we have a safe staffing compliment for the patients, but because we work on an attack response basis, if something happens, we can't guarantee that we have enough staff to keep our staff safe. I think that that recognises that we put clinicians and nurses and front-line professionals in harm's way sometimes in our health and social care settings that their safety should be as patient safety. The meaning and intent of my amendments 4 and 5 also extend that to recognise that this bill goes further than just hospital settings and service settings as well. I would just like to say a word about the cabinet secretary's amendment 15. Our interpretation of that—I hope that you will clarify that in her remarks—is that the focus of staff and wellbeing is only when patient care is compromised according to amendment 15. I think that wellbeing and safety should be a concern at all times of our staff, and not just when patient care is satisfactory. They operate, as I have said, in a fluid and dynamic environment, in whilst everything may seem fine and well-staffed and safe, it may change in a heartbeat. As such, I think that we will oppose amendment 15. Thank you very much, and I call the cabinet secretary to speak to amendment 15 and other amendments in this group. I appreciate the valid aim of amendment 3 to ensure staff wellbeing is considered in ensuring adequate numbers of staff. With that legislation, we seek to ensure safe, high-quality services. Success will create a richer circle of better outcomes for patients together with the improved wellbeing for the staff. Evidence demonstrates that one does indeed affect the other. An almost identical provision to amendment 15 in relation to staff already exists in health and safety legislation. We would want to avoid replicating any duty that already exists in primary legislation, and we must also be mindful that employment and health and safety law are reserved matters into which we should not stray. I support the aims of amendment 3 and we already have as a guiding principle in ensuring the wellbeing of staff, but given my concerns on the specific wording and the risk that I believe that poses in terms of reserved legislation, I would propose that the replacement amendment 15 answers the request of the Royal College of Nursing to include staff wellbeing in the duty on care service providers to ensure appropriate staffing, while aligning with the rest of the bill and, most importantly, keeping the primary focus of the legislation on the welfare of service users. Staff wellbeing is crucial, I agree, but it is how it impacts on the service itself that we should be looking at here, while at the same time maintaining our responsibilities in relation to reserved health and safety legislation. I have no concerns with amendment 4, given the clear aims of the bill to secure safe and high quality healthcare. However, amendment 5 is, I believe, unnecessary, given that the term healthcare is already defined in section 12-IG as meaning a service that is a service for or in connection with the prevention, diagnosis or treatment of illness. Amendment 5 duplicates that definition and, on that basis, I ask the committee not to support it. My amendment 16 lists factors that health boards should consider when fulfilling the general duty to ensure appropriate staffing. It responds to stage 1 written evidence from the RCN and the Royal College of Physicians, Edinburgh. It follows a similar format found in respect of section 6 for care services. It requires factors such as local context and the needs of patients to be considered. I would also point out the reference at subsection 2e of amendment 16 to have in regard to appropriate clinical advice, which I know was suggested by Mr Cole-Hamilton during the stage 1 debate for inclusion. The Scottish Government's position is that amendment 16, in conjunction with further references throughout the bill, to seek appropriate clinical advice, as defined in section 12-IG, is the appropriate way of ensuring that all staffing decisions are informed by clinical advice. I therefore ask the committee to support the amendments in my name, but not to support amendments 3 and 5. I have George Adam. I have listened to what the cabinet secretary said and what Alex Cole-Hamilton said. Amendment 3, if I am getting this right, we can possibly find out from someone else who is summing up with Alex Cole-Hamilton. I am a bit concerned about the fact that there could be stepping into reserved health and safety legislation, and there is no way that we could work on this over the coming weeks to make sure that we can find a way to get it right. I will be back in amendment 4, because I think that you get the balance right in that one. It might be a case that, with amendment 3, we can try to find some kind of work-round or compromise on it. When we start moving into legislation that is not defined by here, we get ourselves into muddy ground, and I just want to make sure that we are in a safe place. Good morning, everybody. I just want to add a comment that I shared with George Adam's concerns about creeping into or encroaching into reserved legislation. In a lot of my constituency work, that has come up as well about what is health and safety, which is a reserved matter, versus what we can do in our own devolved Parliament. I am interested in just looking at making sure that we are clear in how we pursue legislation that we are not encroaching into reserved laws. I am looking for other members of the committee. If there are none, I will call on Alex Cole-Hamilton to wind up and to press or withdraw amendment 3. I am not persuaded that amendment 3 would fail a competence test in respect of this Parliament and the work of this Government, because the first letter in Shinari, which is what we apply to children in terms of getting it right for every child, is safe. It is not a reserved concept. Yes, health and safety legislation is reserved, but working in a policy context to make our staff safe should not be seen as outwith the purview of this Parliament. To that end, I press the amendment in my name on 3. Thank you very much. The question is that amendment 3 be agreed to. Are we all agreed? We are not all agreed. Can I therefore see votes in favour of amendment 3 and those against? The vote is 5 in favour and 4 against. Amendment 3 is therefore agreed. Can I call amendment 4 in the name of Alex Cole-Hamilton, already debated with amendment 3, Alex Cole-Hamilton, to move or not move? Thank you very much. The question is that amendment 4 be agreed to. Are we all agreed? We are all agreed. Can I call amendment 5 in the name of Alex Cole-Hamilton, already debated with amendment 3, Alex Cole-Hamilton, to move or not move? Thank you very much. The question is that amendment 5 be agreed to. Are we all agreed? We are not all agreed. Can I therefore see votes in favour of amendment 5? The vote in that amendment is 5 in favour and 4 against. That amendment is therefore carried. Can I call amendment 15 in the name of the cabinet secretary, already debated with amendment 3, cabinet secretary, to move formally? Thank you very much. The question is that amendment 15 be agreed to. Are we all agreed? We are not all agreed. Can I therefore see votes in favour of amendment 15? Can I see votes against? On amendment 15 there were 4 votes in favour and 5 against. That amendment is therefore not carried. Can I call amendment 16 in the name of the cabinet secretary, already debated with amendment 3, cabinet secretary, to move? Thank you very much. The question is that amendment 16 be agreed to. Are we all agreed? We are all agreed. Now move on to the next group of amendments on real-time staffing assessment and risk escalation process. Can I call amendment 17 in the name of the cabinet secretary, group with the amendments as shown in the grouping, cabinet secretary, to move amendment 17 and speak to all others in the group? Thank you, convener. During the stage 1 debate, I undertook to lodge an amendment placing a more explicit duty on health boards, relevant special health boards and the agency 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. I believe that amendment 17 and the other Government amendments in this group achieve those aims. Healthcare settings are dynamic working environments where situations can change swiftly. The bill already places a duty on health boards, special health boards and the agency to ensure that, at all times, suitably qualified and competent individuals are working in such numbers as are appropriate for the health, wellbeing and safety of patients and for the provision of high-quality care. The proposed amendment 17, which inserts new sections into the National Health Service Scotland Act 1978, takes this a step further by putting a duty on those bodies to have in place arrangements for the real-time assessment of staffing requirements and for the identification of risks caused by staffing to the health, wellbeing and safety of patients, the provision of high-quality healthcare or, in so far as it affects either of those matters, the wellbeing of staff. As is only logical, those criteria for compliance would mirror the criteria in the general staffing duties on boards in section 12IA, which we have already debated. It sets out that a procedure must be in place for any member of staff to identify and report such a risk. A procedure must also be in place for the mitigation of such risks by the person with lead clinical professional responsibility in that area. Where it has not been possible to mitigate a risk at a local level, the proposed new section 12IAB puts a duty on health boards, relevant special health boards and the agency to have in place procedures for the escalation of the risk to the appropriate decision maker within the organisation, who must seek appropriate clinical advice as necessary in reaching any decision. That is in recognition of the importance of the professional voice in the decision making process. The amendment was developed in collaboration with stakeholders from professional and trade union bodies and with nursing and medical directors. During discussions about what the proposed amendment should seek to achieve, the feedback was that it was not only about putting in place a new process for real-time assessment and escalation of risks, but it was also about ensuring that, where staff have highlighted a risk, they should receive feedback on any decisions made as a result. With that in mind, the amendment sets out that decisions must be relayed back to all those involved in identifying the risk, those involved in attempting to mitigate the risk, those involved in reporting the risk and those who have given clinical advice. Any of those individuals may record disagreement with the decision reach. That also applies at the level of the board. If a nurse director or medical director, having offered their clinical advice to the board, felt that they disagreed with the decision subsequently reached, then they have the ability to record that. Of course, any nurse or doctor will also act in accordance with their professional code, which would require them to note their disagreement. The amendment that I have brought forward requires boards to have in place a procedure to allow nurse directors, medical directors or any member of staff to record their disagreement. Regards should be taken to professional clinical advice at all levels of the organisation, and clear processes should be in place for transparency of decision making having taken regard to such advice. That is why I have ensured that the need for clinical advice is woven through every provision in this bill. It should not be a standalone provision and should not just refer to one person or a small number of people. The health board would also be required to raise awareness of those procedures among staff. Amendment 39 places a duty on the health board to include in their annual report details of how they have carried out their duties in relation to the new real-time staffing assessment and risk escalation provisions, thereby providing transparency and accountability for the delivery of the provision. Amendment 41 clarifies that the guidance to which every health board and the agency must have regard may, in particular, include provision about procedures for the identification, mitigation and escalation of risk caused by staffing levels and arrangements put in place under sections 12IAA and 12IAB. During discussions on the proposed amendment, the majority of stakeholders were keen to point out that they already have processes in place for the assessment and escalation of risks. They did not therefore want to reinvent the wheel and their preference was that the real-time assessment and escalation amendment would not be overly prescriptive in setting out the processes and procedures that must be followed. Furthermore, the bill needs to work across a variety of settings and also needs to take account of the changing landscape brought about by integration. I am therefore keen to avoid placing too much administrative detail in the primary legislation, as that would risk being that legislation being too inflexible. That sort of detail, in my view, is better set out in guidance, which can be amended over time should changing needs require it. Amendments 48, 49, 50, 52, 53, 54, 55, 56, 58, 59, 60, 62, 63 and 64 insert references to new sections 12IAA and 12IAB into section 5. In doing so, they apply the provision set out in these new sections to the special health boards, which provide clinical healthcare, such as the state hospital board, NHS 24, the national waiting time centre board and the Scottish ambulance service board, by amending their governing secondary legislation. Amendments 51, 57, 61 and 65 are technical amendments. Section 2 of the bill places three duties on health boards and the agency, one to have regard to the guiding principles and two on health boards when commissioning health services from other providers. References in the bill to section 2 refer to the duties to capture all three. Those amendments therefore change the references at section 53B, 56B, 59B and section 512B respectively from duty to duties to clarify that all three duties apply to the special health boards covered by section 5. I will now, if I may, move on to amendments 17A and 17I, I think, lodged by Mr Stewart. I am happy to accept the majority of these amendments. However, amendment 17D and 17I are, I feel, unnecessary. Scottish Government amendment 39 will, as I have just described, add the duty to have a real-time staffing assessment in place and the duty to have a risk escalation process in place into the list of duties that health boards and the agency must report on under section 12IE. This amendment, coupled with amendments 37 and 38, which are to be debated under group 14, therefore set out that health boards and the agency will, within one month of the end of the financial year, have to publish and submit to Scottish ministers a report setting out how, during that financial year, they have carried out their duties under these new sections on risk assessment and escalation. I would therefore ask Mr Stewart not to move those amendments. Amendment 107, also lodged by Mr Stewart, sets out that every health board and the agency must establish a risk management protocol to identify, monitor and assess risk associated with complying with the general duty. In essence, much of what is suggested in this amendment is already covered in section 12IEA, the duty to have real-time staffing assessment in place and 12IEAB, the duty to have a risk escalation in place, which I just discussed. My intention would be to set out in guidance rather than in primary legislation the steps to be taken by the health board or the agency to mitigate any risk associated with complying with the general duty at 12IEA. That will allow greater flexibility, particularly as we move towards multi-disciplinary and multi-agency working, which might open up new avenues for dealing with some of our current staffing issues. With that in mind, I would ask Mr Stewart not to move amendment 107. However, I would be happy to meet further with him to discuss whether any further amendment could be made to sections 12IEA or 12IEAB that might satisfy his wish to see health boards put in place some kind of risk management protocol, setting out the actions that individuals with lead clinical professional responsibility may take to mitigate risks locally. I am afraid that I cannot support amendment 123 lodged by Miles Briggs. I understand and agree with the intent, but it raises for me a number of concerns. First and foremost, I feel that much of what this amendment looks to achieve can already be achieved through the Scottish Government amendment 17. Through the proposed new sections on real-time staffing assessment and risk escalation, any member of staff will be able to report if they feel that the health board is not complying with the general duty and action will then have to be taken to mitigate this or reasons provided for not doing so. If it is not possible to mitigate a risk locally, it will have to be escalated up through the organisation with those making decisions having to take appropriate clinical advice before doing so. All those involved in identifying, reporting, escalating or providing clinical advice on a risk must be informed of any decision made as a result and there must be a procedure in place for them to record their disagreement with the decision if they wish. It seems to me that this amendment is in essence about ensuring that the professional of voice is heard and I am very much in agreement with that aim. That is why section 12ib, the duty to follow the common staffing method, already includes a duty to have regard to appropriate clinical advice. If amendment 17 is accepted alongside amendment 16, which we have already debated, both the general duty for health and the duty to have a risk escalation process in place will also include duties to have regard to appropriate clinical advice. A further concern relates to the way in which this amendment attempts to delegate operational responsibility without also delegating legal accountability. Who is to be held accountable if something goes wrong when the health board has carried out all of the procedures and have followed the advice of the relevant designated person to the letter? The amendment, in my view, creates basic legal uncertainty on this vital point. We would also need to be clear how it sits alongside existing professional duties. I can see merit in ensuring that where a decision is escalated all the way to the board that there is clarity about who can offer clinical advice at that level and that the board must seek it, must have regard to it and clearly identify how that has informed the final decision. However, it is important that it is clear that final accountability must sit with the board as no decision can be taken in isolation. Were we to progress with amendment 123 as it stands, it risks the role of the health board being compromised by having a designated person responsible for carrying out the functions that have, in actual fact, been given to the health board through the bill. That would be further undermined by allowing that designated person to sub-delegate those functions further to someone who, in their opinion, is suitably qualified and competent. In the 1978 act, the board is a legal entity. To have a single board member in this legislation, named in this legislation, creates confusion in respect of any future instance where it is believed that the legislation is not being implemented and a court decision is sought. The nurse director has responsibility to provide clinical and professional advice, as does the medical director, and guidance and directions from ministers are used to set out how a board complies with its legal duties through those individuals. It is crucial that we get the detail of any amendment that addresses such a fundamental point. One that I have already set out, I understand and support the intention behind crucial that we get the detail right. For all of the reasons that I have discussed, I am not comfortable that the currently proposed amendment is right. For that reason, I invite Mr Briggs to work with me in advance of stage 3 to develop an amendment that we are both content with and meets what I believe is our shared aim of strengthening the professional voice in decision making. In relation to subsection 1D of the amendment, which sets out that every health board in the agency must make arrangements for the purpose of informing patients and staff of staffing levels, I would be keen to hear how that might work in practice. I would point out that staff numbers alone are not an indicator of the quality of the service. Other factors such as the skill mix of staff also need to be considered. As I have already stated, health settings are dynamic environments and as such, staff may move from one ward to another to deal with changes in demand throughout the day. I therefore find it difficult to see how staff and patients are to be kept up to date with staff numbers in that dynamic situation. Having said that, I have already lodged a number of amendments that aim to strengthen the reporting mechanisms within the bill. If Mr Briggs aims to provide patients and staff with an indication of how well services are running, which I presume it is, I would be happy to discuss strengthening that section even further to include the publication of details on how health boards and where appropriate wards are performing in relation to outcome measures. I therefore ask Mr Briggs not to move those amendments and invite the committee not to support them if he does, on the understanding that I would wish to work with him in advance of stage 3. I move amendment 17 and the others in my name. Amendment 107 in my name seeks to achieve a similar aim to that of amendment 17, brought forward by the cabinet secretary. It is crucial that health board and healthcare providers have processes and measures in place to assess and mitigate the possible risks to their duty to supply appropriate staffing. That could be short-term risks such as members' staff being unable to work because of illness or more longer-term challenges such as the difficulties recruiting and a lack of available staff to vacancies nationwide. Amendment 107 is potentially more flexible to local arrangements and explicitly references the ability for staff on the ground to seek a local solution to a possible risk. It is also important that any risk management or escalation process is appropriate and accessible for staff. It is crucial that staff feel the process work for them, that their concerns are noted, escalated and dealt with, and that individual staff members are not placed in circumstances where they have to operate in unsafe environments and are held responsible for any adverse instance caused ultimately by managerial or financial decisions taken higher up. Having said that, as we have heard, if the Government is prepared to accept my small amendment to amendment 17, I am satisfied not to move amendment 107. Amendment 17A closes a small gap in the process set out by the Government's amendment. In any process, it must set out how individual staff members and employees can notify the relevant person of a risk in the first instance. Just stating identification does not explicitly include this step. Amendment 17B and 17E change the reference from individual with lead clinical responsibility to an individual to ensure that this definition is flexible enough. Amendment 17F and 17G ensure that decision makers must not only seek but take into account clinical advice so decisions are not purely justified in finance. Amendment 17I and 17D seek to establish a feedback loop to ensure that any nationwide risk can be recognised. Amendment 17C and 17I require health boards to go further in really raising awareness of risk management processes by ensuring that employees know how to use them and feel equipped to do so. I call Miles Briggs to speak to amendment 123 and other amendments in the group. Thank you, convener. My amendment 123 looks to place a duty on NHS boards to appoint a designated person to carry out functions on its behalf in relation to the staffing groups. It is the rights of NHS boards are organisationally accountable for duties within this legislation and decisions on staffing are affected by many factors, including patient demand, workforce capacity, capability, finance and the NHS estate. Different executive orders will have responsibility for those, but the entire NHS board remains accountable. As the cabinet secretary has outlined, the NHS Scotland Act 1987 already places specific duties on NHS boards for quality workforce planning and health improvements. Nursing leaders, I believe, have a particular skill, knowledge and experience needed to exercise sound professional judgment in setting nursing staff, managing nursing-related risks to the duty and ensuring appropriate staffing and escalating significant sounds within the NHS board. For this reason, each board should, I believe, appoint a designated person in nursing and midwifery to carry out functions on its behalf. The professional judgment advice and actions of nursing leaders must be placed, I believe, on a statutory footing to guarantee the NHS board to make informed clinical decisions in relation to its duties under the legislation. The health and sport committee's report specifically looks towards an accountable person and to look at how the accountabilities of this are still remaining firmly at a corporate board level, which I think is important. In light of what the cabinet secretary said, I am happy to look towards working with her to bring forward an amendment that we might all agree to. As a former operating room and trauma nurse, I know that things can change absolutely quickly, swiftly and you need to have all hands on deck. I welcome the addition of this real-time staffing assessment and risk escalation process, because I understand that people need to be able to make split-second decisions to provide safe, high-quality care. I also welcome the cabinet secretary's comments regarding the wider health and social care approaches, because we are not just talking about acute care in the staffing bill, we are talking about care across the whole health and social care. To allow flexibility and not be too prescriptive in the primary legislation is what I would support, so that guidance can be developed later on to apply to allied health professionals across health and social care in primary, as well as in acute care. In relation to Miles Briggs amendment, I have concerns regarding that, but I note that the cabinet secretary and Miles Briggs have an agreement that they work together and bring something else forward. Boards are set up, but I have concerns that the confidence of boards will be knocked slightly if a designated person, i.e. as I said in the amendment, would be a midwifery or a nursing person. I have concerns in relation to that particular aspect of it, but I certainly look forward to what comes forward from the cabinet secretary and Miles Briggs, who I take it as not moving the amendment at the moment. I do not want to say anything more, convener, other than to thank Mr Briggs and Mr Stewart for their willingness to work with me for stage 3. Thank you very much, and can I ask David Stewart to wind up on his amendment? Thank you, convener. In light of the cabinet secretary's helpful comments, and I know in part that she is accepting some of my amendments, I am happy not to press the amendments to my name. Okay, thank you very much. The question is that amendment 17A, in David Stewart's name, are you not pressing amendment 17A and 17B already debated? I am not pressing any of the amendments in this section. Are members agreed to the withdrawal of amendment 17A? Yes. Are members agreed to the withdrawal of amendment 17A? Likewise, 17B? It does not matter if it is any way down. That is fine, so these other ones are not moved, and I take it there for 17B, 17C, 17D, 17E, 17F, 17G, 17H and 17I are all in the name of David Stewart, and he is not moving any of these, and he has not moved any of these, and therefore it is not pressing them. Amendment 171, in the name of David Stewart, is that in the same cat already debated with amendment 17, and it is sure to move or not? Not moved. Not moved. Thank you very much. I think that it is 17I actually, not 17I. My apologies, that was actually my misreading of the script. It is actually amendment 17I, I am asking Mr Stewart, and you are not moving 17I. Not made. Thank you very much. Thank you, and the cabinet secretary to press a withdrawal of amendment 17. Moved, pressed. Thank you very much. The question is that amendment 17 be agreed to. Are we all agreed? Yes. Thank you very much. We now move on to the next group, which is an amendment in a group on its own duty to ensure appropriate staffing agency workers. The amendment is in the name of Annis Sarwar. Convener, and unfortunately my colleague Mr Sarwar is not able to make the committee today, but if the committee is agreeable, I would like to move and very briefly speak on the amendment. The amendment is designed, convener, to as a probing amendment and spark a debate, which I think has been welcomed by the cabinet secretary as well. It is supported in principle by stakeholders, but I understand the concerns and number of unanswered questions that I also share. That is why I think it should stay in, so we look at an ascepto way to go forward. I mean, as Audit Scotland has shown, the agency nurses are paid three times the pay of an NHS nurse, and some consultants, for example in my own health board in Highland, have reported, locum consultants have been reported to be earning 400,000 a year, which obviously is a phenomenal sum. The amendment seeks to cap what an agency can charge and not what a health board can spend in total. Obviously, I recognise the important role of agencies when we have a workforce crisis, but the clear point that Annis Sarwar is making is that we should not have private companies exploiting the NHS and public purse. The 150 per cent figure comes from a directive to boards in England and Wales. Of course, while health is fully devolved in Scotland, I think that if we do see best practice in other parts of the United Kingdom, I do not see why we should not follow it. I believe that it is right that the Scottish Government acts to limit the aspiring spend, and workforce tools might encourage the use of more agency. If we have an award that is under staff to avoid shutting it down or closing birds, they might change to an agency. I think that it is important that there are some protections built in. One of the main reasons that boards overspend against such as my own in Highland is that it is primarily down to spending on agency staff. There are wider issues here, and I accept that, but this is a start in making some limit and some cap on agency spending. I look to see if other members wish to contribute. I am very sympathetic to the amendment, but the member who is moving it is not with us, but looking towards some points of clarity more before we vote on it, specifically with regard to the 150 per cent that is being raised and whether or not that would include agency fees, because I think that there is an unintended consequence that there will be a knock-on effect on what individual agency staff then take home and pay. I wonder if Dave Stewart had any information on that. I will come first, though, before Mr Stewart lines up. We will hear if there are other members, if not Cabinet Secretary. Thank you, convener. I want to record my thanks to Mr Sarwar for tabling this amendment. I can agree with him that it is not appropriate for private companies to make such profit at the expense of our national health service. This is an issue to which much thought has been given by both the Scottish Government and NHS boards, but I disagree with the approach that Mr Sarwar has taken. As I approach the close of my remarks, I will outline some of that concern now. I will offer that this is not pressed at this time and that Mr Sarwar and I look to see if we can reach an amendment for stage 3. Currently, by the time health boards go to agency, this will have been processed through existing enhanced Government arrangements. That means that other options, such as the use of overtime and bank staff, will have been exhausted. The only way to provide cover is through the use of agency staff. Decisions about agency use will always be signed off by a senior clinical member of staff. If the decision is taken to use agency staff, that is because the advice from a senior clinical professional is that patient safety is likely to be compromised if an appropriate staff member is not secured. Patient safety has to be the cornerstone of our approach here. We already have a preferred supplier contract, which we use the most and are invited to join. Agencies on this contract supply NHS Scotland staff at rates that are similar to NHS rates of pay, which means that pay rates are capped for those on the contract. That also caps the commission rates that agencies on the framework contract receive to ensure that those agencies cannot continue to make exorbitant or surplus profits for supplying the NHS with key front-line staff. NHS boards have been instructed by chief executive letter to source only from agencies on this contract in the first instance, but we know that if a nurse cannot be supplied through the contract, then a nurse needs to be sourced from an agency that is not on the contract. The amendments that I have put forward creating a duty to have real-time staffing assessment in place and the duty to have a risk escalation process in place will reinforce the position that appropriate clinical advice needs to be sought as part of the risk mitigation process, including if the risk is being mitigated through the use of agency staff. Guidance will set out further detail on this, including the circumstances under which it would be acceptable to resort to the use of agency staff and the board-level sign-off process that I would expect to be in place for procurement of agency staff and the monitoring of the same. The proposed break-glass clause in the amendment as drafted sets a potentially very high bar. What circumstances would be classed as exceptional? If the bar is set too high, this could undermine the principles of the bill with regard to safety and lack the flexibility needed to ensure safe staffing. If we are honest, it is the case that if a board comes to me with a request to pay more than the cap because they urgently need a nurse in an intensive care unit, I will defer to the clinical opinion of the nurse or medical director and I am sure members would expect me to do precisely that. I would rather they were spending their time sourcing that agency nurse and doing everything in their power to ensure the safety of the service than going through an additional bureaucratic process to seek my approval. I would also note that a similar approach has been taken in England, although not through legislation, with the recognition there that there needs to be a break-glass clause to ensure safety and continuity of service. That break-glass clause is used extensively and the nursing agency spend is around three times higher per head in England than it is in Scotland. Given the amendments that I have put forward on real-time staffing, assessment, risk escalation processes and the need to ensure that we take an effective and proportionate approach to reducing agency spend, I would ask the committee to reject this amendment on the understanding that I will work with Mr Sawa to explore if there is a way in which we can agree the best approach to address these issues, including the associated escalation and governance of the process at board level to ensure that decisions are taken at the highest level on staffing. Thank you very much, cabinet secretary. I can ask David Stewart to wind up and press or withdraw amendment 80. As you would the cabinet secretary, this is a vitally important issue, but on the basis and the understanding that the cabinet secretary will meet my colleague Anna Sawa, I will not press the amendment. The proposal is that amendment 80 be withdrawn are members of the committee content to so do. Thank you very much. We move on now to the next group, which again is an amendment on its own in relation to the duty to ensure that appropriate staffing is sufficient number of healthcare professionals. Amendment 90, in the name of Alison Johnstone, is in a group on its own. Can I invite Alison Johnstone to move and speak to amendment 90? Thank you very much, convener. Amendment 90 would ensure that, where ministers have commissioning powers, enough student places are being offered to train a workforce that will better ensure that we are able to deliver the healthcare that will meet Scotland's changing needs. I imagine that we are all agreed that this bill is a starting point. Any Scottish Government must and will surely want to take some responsibility for ensuring that Scotland has the right number of registered nurses, midwives and medical practitioners to deliver the healthcare that Scotland needs. In September last year, over a third of all nursing and midwifery vacancies were vacant for three months or more. Although I appreciate that there has been some improvement in June last year, the nursing and midwifery vacancy rate was 5.3 per cent. That is over 3,000 whole-time equivalents, the highest number of vacancies ever recorded. ISD Scotland tells us that turnover has been increasing for several years due to the increasing number of levers in each year. The amendment also asks that the Scottish ministers take into account NHS board reports when commissioning those places and that ministerial decisions—I think that it is clear that ministerial decisions have an impact on the ability of providers to ensure that they have appropriate staffing. The amendment would also ask that there is a report to Parliament on the commissioning of nurses, midwives and medical professionals. I move the amendment in my name. Thank you very much. Can I see if there are members who wish to contribute on this in relation to this amendment? Just to thank Alison Johnstone for bringing this amendment, I consider something similar to myself and she has our enthusiastic support. Thank you very much. I ask the cabinet secretary to speak to this amendment. In order to ensure appropriate numbers of health professionals, there needs to be robust evidence of the workload needed to provide high-quality care and evidence of what the appropriate staffing levels and skills are to deliver that. The purpose of the bill is to create a framework for health boards to generate and use that evidence in a consistent manner. Once boards are using the common staffing method effectively and consistently and reporting on that, that will, of course, inform national planning. I will set out later an amendment that will require Scottish ministers to report on how the information generated by boards as part of this process has been taken into consideration in setting national staffing policies. I believe that that is the proportionate way to link the legislation to wider workforce planning. Commissioning of student intake in relation to nursing and midwifery already takes into account available data and is agreed by consensus with the nursing and midwifery stakeholder reference group. Scottish ministers do not have the power to direct universities to take a specific number of students, so once we have agreed with the reference group what is required, we provide the funding for that number of places at universities across Scotland. The funding is then allocated to individual universities by the Scottish Funding Council. Universities receive funding only for the places that they fill, and in that way they are incentivised to offer the maximum number of places, but we do not have the power to make them do that. It also requires a projection of what might be needed, improving the data that we use to do that will, of course, help, but with the best will in the world we cannot project for every possible circumstance. Ensuring that we have the right number of staff available is a complex issue. It is not just about setting the number of student places. This is also a recruitment and retention issue, and there is an onus on employers to look to grow their own, as we have seen in our health boards across Scotland, where they look to incentivise and grow from their own workforce. The cumulative effect of the provisions of the bill will, I believe, help us to address this issue and recognise that Scottish ministers, health boards, integration authorities, universities and colleges all have a role to play. I am happy to commit to working with Ms Johnson and others to ensure that the reporting duties placed on health boards and on Scottish ministers create the transparency that is needed for effective workforce planning. On that basis, I would ask her not to press this amendment. Thank you very much, and I ask Alison Johnstone to wind up and press or withdraw amendment 90. Thank you, convener, and I thank the cabinet secretary for her comments. I think that we would all agree that workload and workforce are absolutely inextricably linked. The fact that we are debating this amendment shows that it is within the scope of the bill. However transformative or efficient it might be, we cannot apply workforce planning tools adequately if we simply do not have appropriate numbers of staff in place. I appreciate what the cabinet secretary is saying with regard to the fact that those tools will help us to ensure that in the future, but I think that those issues go hand in hand. We cannot continue to put all focus on the providers. If we want to have a partnership approach, it is a partnership that clearly involves the Scottish Government. Our health boards cannot ensure enough staff are in place if we have not trained enough nurses, midwives and doctors. We are all aware of what has happened previously when ministers have decided that the X number of nurses will be trained, for example, and there is a knock-on consequence. The more that this is a joint decision, the better. The 2017 iMatter survey, in that survey, only 27 per cent of nursing and midwifery staff agreed that there are enough staff for me to do my job properly. I think that this is an important issue. It takes us 13 years to make a GP, so we have to really get a grip on this now. I do not think that we can afford to wait until we have further information. I think that the information that we have in front of us, we are all hearing from constituents who simply are unable to get an appointment with a GP. We have to act together and we have to act now. I think that Scotland's national health service is right that the Scottish Government plays out the largest part that is possible and takes responsibility for ensuring that we have that supply of adequately appropriately trained nurses and medics. On those grounds, convener, I will be pushing this amendment. Thank you very much. The question is that amendment 90 be agreed to. Are we all agreed? We are not all agreed. Can I therefore see votes in favour of amendment 90? And votes against? Vote is 5 in favour and vote against amendment 90 is therefore agreed. We now move on to the next group in relation to the duty on health boards to ensure appropriate staffing in relation to senior nurses. There are two amendments in this group. I call amendment 91 in the name of Alison Johnstone and Alison Johnstone to move and speak to amendment 91. Thank you, convener. Amendment 91 seeks to ensure that senior charged nurses and their equivalents in community teams have the time they need to carry out their important clinical leadership role. Senior charged nurses are key to the on-going delivery of safe care. Indeed, they are key to the successful implementation of the legislation. The Royal College of Nursing supports this amendment wholeheartedly. They tell me, and indeed they will have advised colleagues around this table, that senior charged nurses must be given the time they need to fulfil their clinical leadership role by not being counted in the number of nursing staff required to provide direct care to patients. The amendment seeks to ensure that the non-caseload holding status of nurse leaders, senior charged nurses, is fully realised in practice. I move amendment 91. Thank you very much. In fact, the only amendment in this group, can I see if other members wish to speak? Alex Cole-Hamilton, followed by Emma Harper. Thank you, convener. I thank Alison Johnstone for bringing this amendment today. I absolutely agree with it. I think that this speaks again to the very dynamic nature of the theatre of operations that our nurses work in. I think that we have expected far too much of our senior charged nurses in terms of casework holding in the past. As a result, they have not been able to apply that strategic overview, both of health, safety and cleanliness, but of well-being of both their patients and their staff. For that reason, I will support them. I support the best approach that leadership senior charged nurses and the management team apply in their workforce planning. As somebody who has worked directly on the front line, where senior charged nurses can have the choice or the flexibility to support patient care, support their clinical duties, support student nurses and mentoring approach across the whole board, I find that the dynamic differences in caseload places that are working with senior charged nurses across health and social care means that this amendment would be too prescriptive. I think that we need to allow senior charged nurses to be empowered and be flexible and make decisions based on their individual areas, for instance chemotherapy, operating room or other areas. In my own experience, sometimes senior charged nurses must step in because they are the person that has experience at that particular time. The ability to be flexible in the approach across health and social care, allowing senior charged nurses to be empowered and make the individual choices based on their clinical expertise, is what I would support. I am generally supportive of that particular amendment, but I just wanted some clarification on that. I hope that Alison Johnstone may be doing a sum-up that, in this particular amendment, does not preclude a senior charged nurse from taking on a caseload in certain circumstances in terms of, as Alex Cole-Hamilton said, such a fluid environment. I wonder if, as I say in something, if Alison Johnstone would clarify that for me. I understand that RCNs are keen to see the role of a senior charged nurse made in on caseload holding, and I have had a number of discussions with them on that. My view is that, to put in place such a provision in primary legislation, which is what amendment 91 does, would be inappropriate. It would be inflexible and would not recognise the multidisciplinary approach being taken or the different local contexts in which healthcare is provided across Scotland. Although it may be appropriate for a senior charged nurse in a large ward to be non-caseload holding, the miss may not be appropriate for someone with the same role in a small ward with very few staff, as indeed I saw myself in Friday when I visited my local community hospital, where the senior nurse was very definite in her view that she did not want to be only caseload holding but believed that her clinical role and her caseload role were complementary. In addition, as I have said before, the bill is not only about nurses. It covers a variety of professions. Although the majority of the existing tools for use as part of the common staffing method cover nurses and midwives, over time that will change. Amendment 91 applies only to nurses and does not provide a mechanism to include other staff groups in the future. I cannot support such a narrow, nursing-only provision in a bill that takes a multidisciplinary approach to staffing by covering all staffing groups and to which we have already accepted amendments, which define what that multidisciplinary approach should be, as is indeed promoted by Mr Cole Hamilton. To illustrate the kinds of problems that this narrow, nursing-only provision might cause, I want you to think of the evolving multidisciplinary nature of the teams, for example in rehabilitation or re-enabling services, where the clinical team leader is not necessarily a nurse, maybe a physiotherapist as a team leader, in a team that comprises nurses, physios, occupational therapists, speech and language therapists. Surely there should be the flexibility to ensure that the appropriate person was given time to undertake the leadership role. One further, potentially unintended consequence of this amendment, which I think is worth mentioning and indeed important, relates to the ability to maintain clinical competence. It is essential that senior charge nurses maintain their clinical competence and care delivery in order to maintain clinical credibility and to provide effective supervision and oversight of clinical care. It is much harder to do that if they are entirely non-caseload holding. The issue of senior charge nurses being non-caseload holding has been discussed with the Scottish Nurse Directors Group and I understand that at their meeting on Friday just past, they discussed the amendment and indicated that they did not support it for the reasons that I have described. I think that it is equally important to listen to those nurse directors from across our health boards. The Scottish Government proposed amendment 20, which is included in group 11, which we will come to, aims to achieve a consistent position, consistent by setting out with our multidisciplinary approach of the legislation, by setting out an additional step in the common staffing method, requiring consideration of the role and professional duties of lead clinical professionals, which covers all professions, not only nothing. Because the committee will vote on Ms Johnson's amendment 91 before we reach group 11, I want to take a minute to outline what amendment 20 does so that members are aware of the alternative before we come to this vote. Amendment 20 aims to recognise the unique roles and responsibilities that are placed on all clinical team leaders. It ensures that in carrying out the common staffing method, health boards and the agency must take into account the role and professional duties, in particular of any individual with lead clinical professional responsibility, for the particular type of healthcare whose staffing levels are being set. The Scottish Nurse Directors Group supports this approach, which they believe clearly articulates the role of the clinical leader in the common staffing method. Guidance will set out the detail of what that will mean in practice, but in essence it means that boards will have to carefully consider whether, in particular circumstances, and given the other injuries they are expected to carry out, it is appropriate for clinical team leaders to have a caseload or not. The decision reached on this will then have to be factored in when the health board sets out what its staffing establishment is to be for the coming period. Finally, it is also worth noting that, as part of the common staffing method, account is to be taken of appropriate clinical advice. This clinical advice is to cover all of the steps of the common staffing method and not just the final output. Therefore, senior clinicians will always be directly involved in decisions about whether or not it is appropriate for clinical team leaders in their area to be caseload holding. For those reasons, I ask Ms Johnson not to press amendment 1, but, if she does, for the committee to reject that, knowing that she will come to amendment 20 in part of group 11, which I would hope she would support. Thank you very much, cabinet secretary, and I can ask Alison Johnstone to wind up and press or withdraw amendment 91. Thank you, convener, and thank you, colleagues, for your comments and questions. I think that it is the case very much that senior charge nurses should not be expected to be case holding. They should not be constantly having to plug gaps because of a lack of other staff in regard to the fact that my amendment addresses senior charge nurses alone, while it does. However, I think that we have to take into account that nursing and midwifery staff account for 42.6 per cent, the largest group of the NHS workforce that we have. The amendment title makes it clear that this is about them and the roles that they are meant to undertake with regard to Emma Harper's intervention. I clearly appreciate Emma Harper's personal experience, but the Royal College of Nursing has not presented those amendments on a whim that they have done so after a great deal of consultation and discussion with our nursing and midwifery workforce. I think that whether it is a small community hospital, whether it is a huge bustling—we should not have a huge bustling word—whether it is a big award in a city hospital, from chemotherapy to the operating theatre, rostering should be appropriate anyway. This unique role should be properly supported. Senior charge nurses are involved in things such as complex discharge issues and other issues around flow. If they have the time to take on this co-ordinating role, it can help to produce issues such as delayed discharge. It can improve co-ordination and communication across the teams. Senior charge nurses are expected to manage and develop the performance of a nursing team and manage the practice setting by ensuring the effective use of resources and workforce planning through monitoring workload. I will, Sandra. Thank you for your contribution. I mean, from the very start of this bill, we have worked—this committee worked very hard to ensure that it is multidisciplinary and it is not just about acute services or nursing in that respect. We are now back to, unfortunately, the situation where there are many people that work in hospitals who take responsibility, but we are now back to the beginning from what I can see, and no disrespect to anyone. I get credit to all the people who work in the health service, but there are many more people than just senior nursing clinicians. That is where I have a problem picking up on what the cabinet secretary said. There are multidisciplinary professions within that, so why just a small part? I think that the senior charge nurse is a unique role. It is absolutely unique to nursing and, as I have said, nursing makes up 42 plus percent of the NHS workforce. It helps to coordinate inputs from different members of that multidisciplinary team. I think that it is a key role and I am pleased to push this amendment, having worked with the Royal College of Nursing to ascertain the impact that, if the role is properly focused, if those experienced professionals are allowed to do their job to the utmost, it can have a very positive effect. The amendment is mandatory, such as removing senior charge nurses from case load. My point is that senior charge nurses should already be able to be empowered and allowed to be flexible in their choice and how they roster staff. You mentioned that they should then be allowed to support training if they are not part of the case load, but, in my experience, they can still be part of supporting training if they are scrubbed at the operating table to remove a gallbladder, for instance, because they can conduct and guide and support people in that type of environment. I think that the point of this is that it is just too prescriptive. There is such a wide range of health professionals, senior charge nurses in many areas, and they should be empowered to make the choices themselves as they are in that senior charge nurse role to then determine whether they should pick up a case or not or assign it. It is such a wide-ranging skills required, and I think that the senior charge nurses should be allowed to make those informed clinical decisions themselves without prescribing it on the face of the bill. In practice, only a quarter of nursing staff in Scotland surveyed by the RCN in 2017 reported that the senior charge nurse was non-caseholding, and details of the freedom of information request to NHS boards from the RCN show that, of the 911 whole-time equivalent senior charge nurses identified at September 2017, only 115 were non-caseload holding. We have to look at the fact that we are struggling to recruit nurses, we are struggling to retain nurses. If you have an experienced professional in charge of award, giving leadership, giving security, helping others to develop their careers, that is something that we should work towards. I am incredibly sympathetic to what you are trying to achieve in your amendment, and none of us around here want to write poor legislation. I think that it is important in terms of delivering the outcome of the bill that we do have non-caseload holding within the parameters of the bill. Given that amendment 20 of the cabinet secretary's looks towards trying to develop it, I think that there is now overlap with potential work for stage 3 around designated person as well, and how we get that right. I do not know if there is a way of us looking to bring some work on this before stage 3 to make sure that it is incorporated, because I think that it is an important aspect of the bill, but there seems to be quite a bit of confusion. I think that I probably do have concerns that we may water this down considerably, and that I will be pushing my amendment as it stands. Thank you very much, amendment 91 is pressed. The question is that, on amendment 91, we agreed to. Are we all agreed? We are not all agreed. Can I see an indication of those in favour of amendment 91 and those against? The result of that division is 5 in favour and 4 against. Amendment 91 is therefore agreed to. We now move on to another group with a single amendment. That is on the duty on health boards to ensure appropriate staffing training. Amendment 124, in the name of Alison Johnstone, can I call on Alison Johnstone to move and speak to amendment 124? Thank you, convener. My third amendment this morning, amendment 124, aims to place a duty on NHS boards to make sure that employees receive the time to carry out continuous professional development. It is the case that NHS governance standards do already state that employers will give time to staff for CPD, but, as we are only too well aware, precious time is often lost because of the high demands on staff time. The 2017 Royal College of Nursing UK employment survey reported that the main reason that nursing staff feel that there are too few opportunities to progress in their current job is too few opportunities to access training and development. There are real difficulties there. They feel unable to take time off for training due to the many demands that they face in their work. With that, convener, I will move the amendment in my name. Thank you very much. Can I see any indication from other members of the committee who wish to contribute on this amendment? Emma Harper. Thank you, convener. I won't say a lot, but my former role was as a nurse educator and managed to get NHS and Frees and Galloway to have four educators so that we could support education and facilitate continued professional development. In my current work, I have looked at what education is available and provided out there. I would suggest that this amendment not be placed in the bill at the moment until we can get a real assessment of education out there that is provided and supported. I understand the challenges of getting your CPD while you are on the ward or being pulled in different directions, but I would support that we look further into how we are doing as far as education across other health boards, because I know that in my former health board in NHS and Frees and Galloway there were particular efforts being made to accommodate more focused continued professional development for the staff. Thank you very much. Brian Whittle. I think that this is a very important amendment to the bill. I think that in terms of CPD, in some of the work that I know that the committee is very well aware of around the CTG scan training in periodric words, a lot of pressure has been put on those words to afford this type of development for all the staff in there. It has taken a lot of pressure for that to come to bear. I think that it is incredibly important, not just for the development of the staff in patient safety but also for the staff themselves in terms of retention of staff that they are allowed to continually develop. I think that it is an incredibly important amendment to a bill that we should be supporting. George Adam. Can I just back up everything that Macaulay Gemma Harper said? At the point of view, we have had three or four amendments here where Emma has given us her point of view as someone who is working in the front line, someone who is a professional, and it is a valuable resource that we have here to the committee. On each occasion, we seem to have not really taken that on board as a committee as a majority. On that amendment, I would like to back Emma not for the obvious reasons but for the fact that we have someone here who has been in the front line and knows exactly what is going on out there. Thank you, convener. I am grateful to Ms Johnson for her opening remarks on the amendment, which mirrors the existing section 7 in the bill for the care side. Section 7 was inserted because the bill revokes regulation 15 of the social care and social work improvements Scotland requirements for care services regulations 2011. In doing so, it revokes those important provisions on staff training. It was therefore felt necessary to replicate those provisions into the bill in order to ensure that care service staff still have the same rights to training and development as they did before, but health is a different regulatory environment. I am very supportive of the aims of this amendment to ensure that healthcare staff have similar rights to training, but I have a number of reservations about the amendment itself. The national health service reform Scotland Act 2004 inserted section 121, duty in relation to governance of staff into the national health service Scotland Act 1978, and the staff governance standard was published to support this. The standard already requires all NHS boards to demonstrate that their staff are appropriately trained and developed and goes on to provide some detail around this. The standard, of course, is subject to significant scrutiny and work by the partnership forums, a central part to how we work in our NHS. The amendment therefore duplicates, in part, something that already exists within the standard, and if I may gently suggest to the committee that we do not make good law by constantly duplicating what we find elsewhere. Furthermore, I have concerns around the scope of the amendment, which is extremely white. If we take account of the ever-changing health technologies and treatments, that would be an open-ended, unquantified legislative entitlement, and I question how entitlement would be managed. For instance, who would decide, and how would it be decided, which staff should get priority for further qualifications that are deemed appropriate for work, and do the educational development sectors have the capacity to deliver this? In that regard, I think that the comments made by Ms Harper are very pertinent. Of course, staff should receive training and should continue to be developed throughout their careers. I have absolutely no argument with that point. However, I do not feel that making this a legislative entitlement in this way is the correct thing to do. I have serious concerns about whether it will be feasible or indeed possible to maintain staff and high-quality services if growing numbers of staff are released for an open-ended and unpredictable amount of training and development. As part of the development of each of the workload tools, the amount of time staff should spend on training has been factored into the tool. For the existing tools for nursing and midwifery, there is an allowance of 2 per cent. That equates to 33 hours each year for a whole-time equivalent nurse. I expect boards to ensure that staff receive that allowance since it has been factored into the tools, and if they do not, then I would want to know why. I am therefore happy to commit to working with Ms Johnson, should she wish it and with the RCN and others with an interest to consider what might be done to make the common staffing methodology more explicit about this built-in time for training and the need for boards to meet it. I do feel strongly that this is an important issue and one that must be addressed, but I do not think that this is the correct way to go about it in primary legislation with what is in effect an open-ended proposition. On that basis, I would ask Ms Johnson not to press her amendment and, if she does, the committee not to support it. Thank you very much, cabinet secretary, and I can ask Alison Johnstone to wind up and press or withdraw amendment 124. I will start by addressing Brian Whittle's comments. I agree wholeheartedly that ensuring that our staff have adequate time to develop themselves professionally is more likely to, while it will empower them. It will make sure that they are educated in the latest innovations and developments in their particular field. It will help us to recruit and retain people. It will make them feel valued. George Adam is absolutely right to say that Emma Harper is indeed a valuable resource to the committee and indeed the Parliament and reflects often on the experience that she has gained working in this field. However, it is true that, within a large workforce-like nursing, there will be different views and different experiences. Perhaps that is a result of geography, perhaps as a result of the management that one experienced. I think that it is important that we try and look at this as widely as possible. It is just to add that continuous professional development education is provided in lots of different ways, whether it is off the ward or on the ward in the community. Self-directed learning is part of a professional nurses approach. It is not done within work time quite often, but there are other health professionals that might require bedside on-the-job training. To deliver appropriate learning in order to develop clinical skills, there is such a wide approach that, again, I do not think that it is required to put that into primary legislation when the training of staff that is being described in the other amendment allows a more flexible approach. I would support guidance following the introduction of the bill to continue to focus on how we can best provide education for the on-going recruitment and retention and staff development. In an earlier inquiry, when I was a member of this committee, we heard from the chair of the BMA—I cannot quite recall what occasion that was—but he spoke about the fact that medics actually have protected time for this. I think that it was very favourable to the idea that that should be enjoyed and supported for colleagues in nursing too. It is a fact that the 2017 RCN UK Employment Survey reported that the main reason that nursing staff feel that there are too few opportunities to progress, as I have said, is that there are too few opportunities to access training and development. I appreciate Emma Harper's comments about learning in your own time and self-directed support and so on, but I think that there is something invaluable about the appreciation that is shown when that specific time is set aside for this very important work. I do not believe that that is an open-ended commitment with respect, cabinet secretary. I appreciate your comments too, but health boards and the agencies are speaking about appropriate training. Appropriate training is what we have in place at the moment, but 22 per cent of nursing and midwifery staff indicated—this was in the Scotland staff survey in 2015—that they did not even expect to receive the training that was identified in their personal development plan. That is almost a quarter of staff, so I think that it is time that we looked at this. This is an incredibly important career. Is there a more important one? It is one that we should be investing in wholeheartedly, so I will move the amendment in my name. Thank you very much. Alison Johnstone is pressing amendment 124. This is the final question of this session, colleagues. The question is that amendment 124 be agreed to. Are we all agreed? We are not all agreed. We will therefore have a division. Can I see those voting in favour of amendment 124 and those against? Thank you very much. The result of that division is five in favour and four against. Amendment 124 is therefore agreed to. As indicated at the outset, we will resume stage 2 next week. It is still open to members, indeed members of parliament, to submit further amendments after the point at which amendment 124 was submitted, but the deadline for doing so is 12 noon tomorrow Wednesday 30 January, so any further amendments please by then. We will now suspend for five minutes and then resume in private session.